Washington Correctional Center for Women Complaint Investigation Reports 1997
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COMPLAINT INVESTIGAnON REPORT FORM
May 22,1997
Facility:
Washington Correction Center for Women Complaint No
Address:
9601 Bujacich
Gig Harbor, WA 98335
Persons Contacted:
Surveyed by:
Care Mgr.
CSU
002130
Date Investigated: May 9,1997
. - , . . , Safety Officer
i
a
Kathleen Landberg, R.S.
SUMMARY OF FINDINGS
Allegation # 1: Insects are biting her.
The inmate's health record was reviewed and there was no documentation of treatment for insect bites.
The record indicated treatment for anxiety and a pruritus rash in January and February of 1997. The unit
had been sprayed for insects about 4-6 weeks ago. Although the inmate states she is still being bitten by
"lady bug type flying insects" interviews with staff and other inmates could not validate this allegation.
The inmate is in a lock-down, segregation unit, that could not be inspected at the time of this
investigation. She is scheduled to stay in this unit until at least June of 1997. This inmate was
incarcerated in early 1997 and has spent most of her stay in either the segregation or receiving/closed
custody units.
Conclusion: This allegation could not be substantiated
Allegation # 2: Inadequate heat.
The staff were interviewed and the surveyor was in the hall way outside the inmate's cell. The
temperature was comfortable at the time of the survey. Stafftold the surveyor that the heat is controlled
at the main heat plant and is shut off during the day when the building heats up this time of year. The
inmates have adequate clothing and two blankets if they are cold.
Conclusion: This allegation could not be substantiated.
Allegation # 3: Inadequate ventilation, windows nailed shut.
This unit has central air exchange system and it is a maximum custody unit where the windows are
controlled by staff The windows are closed until May 1 for better ventilation control. The ventilation in
this unit is marginal, however, this is one of the older buildings on campus and capital projects have
scheduled to replace all of these units during the next few years.
Conclusion: This allegation could, not be substantiated.
Allegation # 4: Unclean bathing areas.
There are assigned porters to clean the shower stalls. At the time of the survey all shower stalls in use
were clean. This a maximum custody unit with an average of 15 inmates and maximum capacity of30.
Only one inmate at a time takes a shower and not everyone takes a shower every day. The ratio of '
inmates to showers in this unit is adequate. Note: ratios are different in general housing where there is
more flexibility to take showers.
Conclusion: The allegation was not substantiated.
•
COMPLAINT INVESTIGATION REPORT FORM o'
.
?
/1
OfC. Lj
April 8, 1997
Facility: Washington Correctional Center Complaint #: 001997
For Women
Address:
9601 BUJACICH
Gig Harbor, WA 98335
Persons Contacted:
Date Investigated: March 27, 1997
-...ua"IIIIII~s~,-lF~o~o~d!Js~e~rv~i!£c~e~M~an~a~g~e~r
Kathleen Landberg, R.S.
Surveyed By:
StDOIARY OJ' J'INDINGS:
I met with r
dl" and discussed the complaint. He stated that because of
the high temperature of the dishwasher they at times had a residue build-Up in
the coffee cups. I looked at the dishwasher and clean dishes. All inspected
items appeared to be clean, but the cups were stained and residue could be
wiped out of them.
The concentrated instant coffee used in most DOC facilities has a tendency to
stain the coffee cups. If the cups are adequately washed and sanitized, being
stained is not necessarily considered to be a problem other than from an .
aesthetic point of view.
.
~"""".has been on another assignment with DOC and during that time the
policy he had implemented of bleaching out these items was not being done. He
assured me that this policy would be reinstated immediately.
~ElF
i also showed me the monthly maintenance reports on the dishwasher
tnat are conducted by Ecolab. These reports showed that the dishwasher was
operating as designed.
.
The attached letter from •
indicates that the facility has reinstated
the procedure of destaining cups and plates,
This shoulds correct the concerns of the complaintant. The complaint was not
valid.
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Page 10f 1
5
DEPARTMENT OF HEALTH
Facilities and Services Licensing
P.O. Box 47852
Olympia, Washington 98504-7852
"a~.
. STATEMENT OF DEFICIENCIES
AND
PLAN OF CORRECTION
Sur .. ey Detes
December 8-9, 1997-
or Facility
Licea •• Nu;abar
Washington Corrections Center For Women
Addraas
9601 Bujacich
City
Zip Code
Gig Harbor
98335
Licensing or CertitieaCion Requireaenta U••d
HS-DOC, WAC 246-215 & Multi-State Stds.
~
NOTE: This document contains a listing of the deficiencies cited as requiring correction. The
Statement of Deficiencies is based on the surveyor's professional knowledge and
interpretation of requirements for facility licensure or certification. In the column
Application's/Licensee's Plan of Correction, the statements should reflect the
facility's plan for corrective action and anticipated time of correction.
Stacoment or Derieianelos witb Rer.rooeo Citation
(/I
"u~bor
Applicaot'a/Liconaoo'S Plan or Corroetton with Tloo Table
;2'.3~. 3.Q.
1. Ceiling/wall vents were soiled and dusty
in several areas (e.g. MSU bath areas,
custodial closet G-I, L-A shower,
[. 1-/ ;;. 3{) Lf.e
I
2. Small pipes connected to the heat units in
several rooms in the mental health unit (0-6,
C-2, etc.) were accessible to the inmates.
i.
Ii ::2 30. 3
3. A section of mopboard was loose in G-l /
A-I.
~
1-1 (]qG,;)-
4. There was no air gap/anti-siphon device at
the hose connection at the shower/tub in G-l.
~ N. I ~C .;;.
5. Paint was chipped and the area at the base
of the shower in F-I west was not cleanable.
Also, a section of metal trim was missing at
the air vent over the tub in this room.
I
I understand the deficiency(s) listed and agree to correct
thea as outlined above by the dates indicated. I agree to
send written notification to Facilities &Services Licensing,
DOH, by.k
declaring the extent to which this
plan of correction was completed.
Facility Representative
Date
The plan of correction must be returned to Department of Health within 10 (ten) days of receipt of deficiencies,
12/92Ilfor08.1,. DSHS, 10-10281
Page 1 of 3 Pages
DOH UO.004IREV.
.DEPARTMENT OF HEALTH
Facilities and Services Licensing
P.O. Box 47852
Olyapia, Vashington 98504-7852
STATEMENT OF DEFICIENCIES
AND
PLAN OF CORRECTION (continuation)
December 8-9, 1997
•• a. af '.eillty
City
Washington Corrections Center For Women
Gig Harbor
St.t•••nt af Daflci.nci•• with Referene. Cit.tlan Waeber
~
Applle•• t·./Licon ••• •• Pl.n af Correction with Tie. T.bl.
1/ '-/ /U,I
6. The wooden step at the sink in the child
care room in the education building was worn
and was no longer impervious to moisture.
Ie:, o. ;), b
e /!-
7. The chipped, worn wall in the staff toilet
room in the old gym is no longer cleanable.
~30,Lf.. ~
-Z I-f
8. One exit light in the new recreation
bUilding was not lit and one light in
CCUjReceiving was flashing ..
~
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30 ' 'J-, 6
9. Wet mop holders in new MSU building do not
allow mops to drip over the sinks.
£ 1-/ /
~ Q,
10. The wooden benches in the new MSU shower
area are ~eginning to become worn and some of
the surfaces are no longer impervious to
moisture nor cleanable.
.
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1: /+
I fc,(},;)., b
11. Grout at several showers in the MSC
bathrooms is moldy and/or heavily stained
(e.g. L-wings A&C,K-B, J-C, etc.).
~fi.
'Gl3C,3·e
12. The areas behind the washers and dryers
in L building and MSU were soiled and dusty.
2 /-1
d 3C. '-{,e
13. One sprinkler head in L-C 325 had been
·painted and should be tested to see if it
still operates properly.
~_/~
tJ.30,«
14. The mechanical handicapped door device on
the exterior door of MSC dining building does
not. open properly.
c It
~OC· /
15. Linens/pillows were inappropriately
stored on the floor in K-A wing closet.
Surveyor's Initials I~
DOH SSO-OOSIR£V. 11/891lraraarly DSHS IO-102CI
Page 2 of 3 Pages.
....
i
DEPARTMENT OF HEALTH
Facilities and Services Licensing
P,O, Box 47852
Olympia, Vasbington 98504-7852
-
STATEMENT OF DEFICIENCIES
AND
PLAN OF CORRECTION (continuation)
Surv.y Det••
December 8-9, 1997
KA~e
or FAcility
City
Washington Corrections Center For Women
StAteaent of Dericienci.A vith Rorerence Citation Numbor
Gig Harbor
Applicent'e/Lic.n••e'. Plan of Correction with Tice Tabl.
2/-1 ?-'3 0,3,10
16. Cushions on chairs in several areas,
especially K day rooms, were becoming
torn/worn on the corners.
~3().3,J
£fJ
17. The floor behind the ice machine in K
building was dirty.
2' f./
;;( 30, 3·E.
18. Wall surfaces by the sink and in the main
hallway of the new chapel building were
'
chipped and worn.
Fs
63C,I.F-
19. WAC 246-215-090 There was a large section
of the portable sneeze guard missing in the
MSC dining room.
/-1.$
015,3
20. HS-DOC 015 (3) The was no consistent,
easily retrievable method of verifying
current licensure of professional staff,
especially contract staff. Records were
located in several offices with varying
degrees of completeness.
Surveyor's Initials
DOH SSO-OOSlaev.
__
Il/89)ICoroerlY,DSHS lO-102C)
Page 3 of 3 Pages.
.'~
DEPARTMENT OF HEALTH
STATEMENT OF DEFICIENCIES
Facilities and Services Licensing
P.O. Box 47852
Olympia. Washington 98504-7852
PLAN OF CORRECTION
AND
........-r Dial_
--
_.
12/8 &: 9/97
...
_-"MUltI'
Washington Correctional Center for Women
Clily
as. c.-
Gig Harbor
9601 Bujacich
u..e.......
98335-0017
ewu.~ ~ . 0MlI
HS-DOC Minimum Stds 10/14/94
Alice Payne
NOTE: This docwnent contains a listing of the deficiencies cited as requiring correction.
The Statement of Deficiencies is based on the surveyor s professional knowledge and
interpretation of requirements for facility licensure or certification. In the column
Application' s/Licensee' s Plan of" Correction, the statements should reflect the
facility's plan for corrective action and anticipated time of correction.
I
Statement of Deficiencies with Reference Citation Number
Applicant's/Licensee's Plan of Correction with Time Table
010 ADMINISTRATION OF HEALTH SERVICES
(4) Policies and procedures shall describe
and define a system within each facility
which: (bl encourages and supports
appropriatp., safe, and timely care by
U
qualified personnel.
'S 0' I I,
H
0
b
This requirement is not met as evidenced by:
Through review of policy and staff interview,
it was learned that glucose monitors were
not being tested/calibrated as per
manufacturer's recommendations.
Two types of glucose monitors were noted. •
ODe-Touch II and ODe-Touch Basic.
HaDufacturer's directions for both stated
that a ·glucose control solution test· and a
·check strip· test be conducted ••• daily for
the ODe-Touch II. The ODe-Touch Basic
reeommended to use the check strip daily and
the glucose solution one time a week. The
control solution verifies that the test
strip and meter are working together properly
aDd the correct procedure is being followed.
The check strip is used to verify that the
meter is working properly.
Ho policies were noted which outlined the
glucose control solution testing of either
meter as required.
I understand the deficiency(sl listed and agree to correct
them as outlined above by the dates indicated. I agree to
send written notification to Facilities , Services Licensing.
DOH. by
deClaring tho extent to which this
plan of correction was completed.
Surveyor signature(s):
Facility Representative
'I'be pl_
0' corr_tlOD 1Ial8t be
- .......,_..."'...._ •• - 11-'''',
r.t~
to llepart:meDt
0' Health wit:h1D 10
(t_. ~
Date
0' r_aipt 0' 4.'lcleacl•••
Page 1 of 3 Pages
(
DEPARTMENT OF HEALTH
Facility Licensing and Certification Division
Facilities Survey Section
1112 S. E Quince
P.O. Box 47852
Olympia. Washington 98504-7852
STATEMENT OF DEFICIENCIES
AND
PLAN OF CORRECTION (continuation)
--
12/8 &: 9/97
,
.'
:~
-'-oC ... 'Utr
« ...
Washington Correctional Center for Women
Gig Harbor
IStatement of Deficiencies with Reference Citation Number
H5
llrAPPlicant's/Licensee's 'Plan of correction with Time Table
os-u~
050 INFECTION CONTROL (1) Policies and
procedures shall provide for the development
and implementation of infection contrel
measures which are consistent with the DOC
infection control program; guidance published
by the DOH; rules and regulations published
by the Dental Disciplinary Board; and
applicable standardo published by the
Division of Industrial Safety and Health,
Department of Labor and Industries.
This requirement is not met as evidenced by
the following:
1. Through facility site review and staff
interview it was learned that the storage
system for glucose monitoring equipment for
individual inmates had the potential for
transmitting blood horne pathogens.
%ndividual "baggies· were stored together in
a plastic box with contact between individual
·haggies·. %t was noted that one of the bags
had what appeared to he blood on the outside
of the hag. Dried hlood has heen shown to
harhor active Hepatitis B virus for several
days. There is potential for the nurse
handing the baggies and inmates whose baggies
have touched the contaminated baggie to
potentially be exposed to blood borne
pathogens.
2. Collection tubes of blood in plastic bags
were noted in the laboratory area. Through
staff interview, it was learned that these
bags are carried to a collection site in the
bags. Department of Labor 29 cn Part
1910.1030 under Methods of compliance
(d) (xiii) (C) states that spec~ens of blood
or other potentially infectious materials
shall be placed in a container which prevents
leakage during collection, handling,
processing, storage, transport or shipping.
Surveyor's Inicials
___
Page 2 of 3 Pages.
... '
DEPARTMENT OF HEALTH
Facility Licensing and Certification Division
Facilities SUrvey Section
1112 S.E Quince
P.O. Box 47852
Olympia. Washington 98504-7852
STATEMENT OF DEFICIENCIES
AND
PLAN OF CORRECTION (continuation)
_. -
12/8
_., ......11...,
Washington Correctional Center for Women
Statement of Deficiencies with Reforenco Citation NUmbor
&: 9/97
.'oy
Gig Harbor
Applicant's/Licenseo's Plan of Correction with Time Table
:If t:he specimen cou1cl puncture t:he primaxy
container, t:he primaJ:y container shall be
p1acecl withiD a secondary container which is
puncture-resistant in adclition to the above
characteristics.
S\&%veyor's Initials
_
Page 3 of 3 Pages.
,"
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•
.1
STATE OF WASHINGTON
I
I
DEPARTMENT OF HEALTH !,.
p.o.
IIOJc 478$2 • 0IyrttpM,
WalhinJfod NSfU.1,8SZ
I
I
!
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I
To:
From: Kaahlecn Landberg, Public Health Ac:Msor
Re:
New ConstIUction and New Restraint Bcd.
I,
.
I
Daring the surwy of July 3, 1997 the following concerns ·were ~otcd:
/~ P;.~tJ
4. e
II
.
·
i
1. The water &om the shower heads in the new units sprays bey~d the elevated
contaiOluent rims that ~ constructed inside each shower staB. The only floor drain in
this area is within the containment area and water that splashes oUtside this banicr
becomes hazardous with no place for drainage.
;
:
~
~
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2. The shower heads arc not adjustable and arc mounted so cl~ to the wall that
washing hair may be very difficult.
!
,I
/' fI "}:3 f) 5". ~3. The mea mounted in the custodial closets do not allow ~ mops to drain into
~
.
the mop sink. The wet mops will drip onto the floor creaJing I hazardoous condition.
I
f}jJ)
4. The new molded restraint bed and plastic cuff restraints with Washable covers
COITCCt the concerns that surveyor Judy Bishop had about the bed: previously used to
restrain inmates.
f H ~ 3 ~. '1, as· There was a broken window in G~llS-G.
i
Ifl can be offurthcr assistance to you please contact me at 597-4335.
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..
STATEMENT OF DEFICIENCIES
AND
PLAN OF CORRECTION
DEPARTMENT OF HEALTH
Facilitia lIIII1 SerW:a I.il:aIsiJIs
PO Box 47852
Olympia. Wa.sbilJstou 98S04-78S2
Sunwy DaliDS
10127198
NuaaoCFKilicy
~
u-. NIIIIIbcr
AddraI
.
City
ZipCodo
Gig Harbor
98335
WashingtOD Corrections Center For Women
"~"".-.
9601 Bujacicb
~
..
:#
I..iamiqorCati6Clltiaa ~ Utcd
Alice Pavne
WAC 246-215 Food Service. HS-OOC &: Multi-5tate Stds.
NOTE: This document contains a listing ofthede6aencies cited as r~ corrections. The Statement ofDeficiencies is
based 00 the Surveyor's professional knowledge and interpretation of requirements for filcility licensure or eertification. In
the column Applieation'slLic:eusee's Plan ofCorrectioD, the statements should reBeet the facilityt s plan for corrective
actioD and anticioated time ofcorrection.
App6caDtt slLicensee's Plan ofCorrectiOD with
Statement of Deficiencies with Reference Citation Number
II complete 11/16/98
I. Main kitchen: WAD 246-215-080t6l..Iwo-·OMoiU.L..\,o!:~
bad expired food worker's permifS':- •., c:-..-" 1"'\ /
-,5 ' D
JP pomplete 11/13/98
~ ~'fp.
2. WAC 246-215-1ge(lO)(d) The broken porcelain handwash
sink in the kitchen was not cleaeable.
~
2.
3. WAC 246-215-
3.
preparation
F~)
e
e at the tray
ea was jtQ.t cleanable. ":3!i!f3
. r S. /5 0,. Z»
4. WAC 246-2 I5-100(8)(c) The fan covers in one walk-in
rUDe Table
4.
Replaced 11/5/98
Damaged wall surface at tray area will be
replaced by 12/4/98•
Corrected 10/29/98
refrigerator were soiled and there was mold on the ceiling ofthe
unit.
~
~
C ~_
C')
.10 (), 'lr.
5. MSC kitchen: WAC 246-215-140(1)(a) At least twice during
this survey the kitchen door was a en to the outside for over 5
an" lower over the door h
activated.
minutes
Also. the screen was missing from the pantry window which was
pen for ventilation during the survey.
5.
Instructed food service to monitor on and
off switch and ensure that it is operating
at all times - 10/29/98.
~ €CE -. V ~ ~ ..
Screen replaced - 10/28/98.
DEC 141998
I UDdcntmd the: dcficic:ucy(s) listed aad agree to com:a them as oudioed
above by the dates indic:aecd. I agree to SCIld wrinca DOtitieaticm to
FlICilitics & services wccnsing, DOH.
by P e b r ua r y . 10, 199 9icclaring the e:octent to which this
plan com:ctiOD was completed.
of
The plaa ofcorrection must be returned to Departmalt of BeaJtb withia 10 (teD) days of receipt of deficicades.
WCCW98.COC
Page 1 on Pages
. .. ...
STATEMENT Of DEFICIENCIES
DEPARTMENT OF HEALTH
Facility Li&zasiDs aad Ccnilicalillll Divisioo
POBox478S2
Olympia. Wosbinpn 98SQ4.7851
AND
PLAN OF CORRECTION (c:ontiDuation)
SlllW)'Dua
~oCFdty
10127/98
WashiDgtOD Corrections Cemer For Women
City
Gig Harbor
.
1L.._2.S~tat~em~ent~o~f~D~eti~Cl~·ena~·es~with~·~Refi~~ef~enc~e:::..:C~itaU=·~on~N~umb=er=-_.1....~Ap:%tp::::Ii,=.;m:::1t:..:"sILi::.=·:::c:eus=see=.::"s:.,:PIan.=:..::o::.f.=C;:orrectl:.:.::::::·:;:;OD::..:.:::with,::·::..:Ti=IDle=-:T:.;:ab:::;l::;:e__
~46-215_~
Work order submitted 'for repair by 12/4/98.
7. WAC
ne grout at the dishwasher was
moldy and loose and the area was Dot cleanable.
~ft@t;!
i;;
8. WAC 246-215-120(10)(d) The hand wash'
order submitted for repair by 12/4/98.
m
wasnm~;_~
1
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9. Ceiling!
In I-unit 101 bathroom were stained and 1 9.
moldy. AJso. nail!_were begimg..tocome through from the
sheet rock in
walls in 151 bathroom.
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the
C; IJ ~/~
ho.
f
I:
-unit, 324 & 351 that were
mnriiiOfcfUii(rertllelil~)t.It.
12.iIed.
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Ill.
~
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14. Note: This surveyor was unable to determine if plans for
remodeling of the infumary had been approved by DOH
Construction Review Unit.
Work order to remove and replace old
grout by 12/30/98
112.
I
Custodian will clean vent by 12/5/98
i
Work order to secure oxygen bottles
by 12/15/98
13. Several portable oxygen bottles in exam rooms, storage areas j 13.
?;.infirmarynurse·Ssmio~ot
secured to the walls.
l1~s, /LfCJ·,~
Dishwasher will be purchased for area
I
~S' I 0 () . ~....,)
£!!
12/30/98
i
/).;70-
10. A three compartment sink or dishwasher bas not been
included in the plans for the infant area.. An appropriate method
les. if necessary • must be
for sanitizing dishes
,:
pro~d
.
.
Work order submitted for repair by
i
1
DEC 14 1998
1
I
;--:'OIU'i.~,::,.,:..;l1 t~ ~~~
i
15.
consistently followed policy I
procedure for disposal of used e
)ors.
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Surveyor's Initials
£6-:- -----
DOH Sso.ooS(REV. 09197)
\15.
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Ucei'sinp
Draft procedures for safety razor
disposal by 12/30/98
! Representative's mid
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Page 2 ofJ Pages
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DEPARTME.NT OFHEALm
STATEMENT'OF DEfICIENCIES
PO 8alt478S1
Olympia. W"binpm 98504-78S2
PLAN OF CORRECTION (conrim'3licm)
FaciIily UccasizIs aad Cc:rIi&catiarl Divisiaa
.
A!UJ
,
s-.,o...
10JZ7/98
Haaal,..,
Washington Corrections Caner For Women
cay
;.
.'
Gis Harbor
"
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; ·4
StatemeDt ofDeficiencies with Reference Citation Number
Applicam's!Licens='s Plan of Correction with TUDe Table
i
16. Ceiling vents were soiled in Education building inmate rest
16.
room aad in G-soudJ bathrco
,
was loose at the· i
--f1/,;?:30. 3, ~,
\
tub G-south b.d"w
I
~
Work order submitted to clean vents
and secure loose grout around tub
.by 12/30/98
17. Inmate laundry areas in G-unit and 256 were washing some
17.. Work order submitted to raise water
contaminated laundry. These units do not have hot water at a
!
temperature to 140 degrees by 12/5/98
minimum of 140 degrees F. Appropriate water temperatures
must be provided for areas where cornaminated items are
j
_._-__
washed. Also. the proposal to wash ~ed batches Ofl~dry90;
~
( more thaD one in
th
j /1.(97'(,,/' \P
140 degree F. temp.. ..
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18. One washing machine in G-unit was inoperable and hoses on
om.rZZi'/~'
18. The Plexiglas used at the base oithe shower stalls in the 256
unit were not comgletelv sealed at the floor and inmates have
~mplainodof~'how ...... ~usmgth.
,toilet.
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j 18.
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19.
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19, The location of the sanitary napkin waste containers in the
i 0
256 unit is just above the hip ofa person· using a toilet. This
~ 2 •
creates an inIeaion control problem with e:tposure to body
!
fluids. Also. the staffcommented that the size of these comainers ~
was quite small and often the
oers were eel beyond
\
capacity in a very sho
~
f
·me.;l5
CJ
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Work order submitted to repair washer
and check hoses in all units for
possible replacement by 12/30/98
Determine if plexiglass can be sealed
closer-to floor, repair if feasible
by 12/30/98.
Inquiring into ordering larger waste
containers or ordering a second waste
container and raising the level of
approved containers by 1/29/99.
0 . . . . .,
DEC 14 1998
," ~~C:HL~~";' ..to.
:~•
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..,.,-ot \: :~ ....
UC&I'Sln9
Surveyor's lnitiaJs ~L,-t4.L4/l'~1
_
COH S5Q.OOS(REV. 09'"l;f1.'
Rq>resenWive',lDilials
Page 3 or:; Pages
AWl &$1#(&
. . . . . . . h.l".
.
~~~~
~.
Facilities aDd ScniceS Licensing
POBox47852
Olym~ Washington 98104-7852
t
N.mo oCFaeilily
Washington Corrections Center for Women
Address
. P.O. Box 17
AdmiIIisIr.IIor
"rY
o\ ' .
t
DEPARTMENT OF HEALTH
~~
~
l"
1.~1t:.
.
"
STATEMENT OF DEFICIENCIES
AND
PLAN OF CORREcnON
._",
Survey Dales
"
l
Facility #004417
~g Harbor, WA
;S~
~ or Ccrti&clItiou IUquircmeuls Used.
Dept. ~
~
IIA _
I r ~ iv
Liccase Number
~
HffRS
retr f
10/27/98
\..~,.,:..
ElVEc
DEC f 41S98
CoP~
~ .~
..J!
~ .:c., 1/ "'Jft'~.'A
~ 1711/;' f
• ••
fa
.
Minimum Standards ofHealth Semces DiVISIon r OperatIon
.J
and Maintenan~ ofH~~ Serv.ices in Correctional Facilities
.."..\~..#"
ffiS-DOC)- Major Institutions
NOTE: This document contains a listing ofthe deficiencies cited as requiring corrections. The Statement ofDeficiencies is
based on the SUlVeyor's professional knowledge and interpretation of requirements for fiLcility JiceDSW"c or certification. In
the column Application'slLicensee' s Plan ofCorrection, the statements should reflect the fi1cility's plan for corrective
action and anticiDated time of correction.
•
j , SuperiRtendent
~" .•#./.::;"
Statement ofDeficiencies with Reference Citation Number . ·1_-=A:..:lpI:.I:P~Ii;=.:can=.t'=sILi=·censee==·,:,S.:.P=lan=-=o=-f=c=orr=ectl=·~o:.:::n":'WI.;.;;·th;;:;;..:T=im=e...;;T~ab;;.;l:.:.e---l
!
INITIAL COMMENTS
DEPARTMENT OF CORRECTIONS SURVEY
li
i
This sulVey ofthe Health Services unit at the Washington
Corrections Center for Women was conducted by Marieta Smith,
RN MN, and Kathleen Landberg. RS.
I!
I
~
. SUlVey dates 10/26/98 • 10/27/98
!
R&A#026601
f
~
,~
I:
HS-DOC 010 - ADMINISTRAnON OF REALm
SERVICES
(2) There sbaD be written, current policies and procedures .I
developed and implemented to address the health care needs 1
of offenders in each facility. Policies and procedures shall
~
be:
. ;
(a) Available to all authorized personnel in each faCiJity.~.
(b) Reviewed by the health authority, medical director or i
other physician, and superintendent not less than every ~
two years and revised as needed.
(3) There shall be documentation which reflects the review
~
of applicable policies and procedures by health care staff.
.'!
s.
~ECEtVEl
DEC 1 7 1998
i
!
:
!
Surveyor
Signature{s):-.mi,.:..Cv~!~;1u..-.;,1~~"""'-!.I:.kLb-
~
_
I understand the deficiency(s) listed and agree to correct them as outliDcd
above by the dates indicated. I agree to send written notification to
Facilities & services Licensing, DOH,
.
by
,
dec:laring the extent to which this
plana{correc:tlon
completed.
! :l.71i!c
,"
"
J~-I-qy
Date
The plan of correction must be returned to Department of Health within 10 (ten) days of receipt ofdeficiencies.
WCCW.OOC
- ··M t, vWiWiMiU.aaiQ.Q
.
C J.
'
J" 5 . •t.&.4ttkh
Page 1 of9 Pages
. 12/07/1998
.~
12:30
286-705-6654'
DEPARTMENT CF I-£ALTH
DBPAIlTMI!N1' OFHEALTH
PAGE
83
STA'I'I!JONT OPDEFIaBNCJES
. AND
PLAN Of CORR!CJ'JON (coadetltiao)
F.aIit)' ~ ad CatiIIoIticaDmlicD
POIka47852
a,.."'...... ft»t.7IS2
""'010/27198
CiIY.
Gia HIIbor, WA
1. Correction: The temperature control log will be re-designed to
reflect the monitoring of each refrigerator. the location, the
acceptable range of temper:ature. and the signature of the
inspecting nurse. The infection control nurse will desIgn and
implement a procedure and traini!'1g program for the nursing staff.
Fa1diDp:
'11no rcfiiacrason. wac 10catecl widu tile bedb care Wli&: A
IJDIIJ medication ~r in tile medicatiOIl room IDd two
rdifaenton. OlIO
ud ODe tma1I, ill tb t.botatoJy area.
.
.
.se
Monitoring: 'The infection control nurse will develop a monitoring
,system and incorporate monitoring into next year's CC?ntinuous
Quality Improvement Plan,
!
Responsible Person: Diane Winniford. RN3
I
'I
III a awwal ea1itIed "Shift 1 (2200.0600) !lespoDlibilitiet", flJ6
Completion: January 1, 1999
WIder Tuk 0utl1De ItaleI that tba DIgbr: !Ihift staffmoe il
respoDlib~ for ~8 reftiaerator lemperaturel. Two "
!
re&igerataf 1• .0Ge merbd "smaD" and the od\cr"~ •
I
doc:umemed tIw the tamperaturcI were cbecbd every nigbt.
[
'I'bo lop did DOt dCllipate wbn tbo soWI and ~
'I
rdipratoll W'eI'ClIoc:ltcd. DOf the ac:coptable ruse of
tempcntuRt. They also did not ideatDYlIOd trad: the sec:ood
IlI1II1 Rftipqtcr. ,
Failure to dtsipu and verify bi&h _low tcmpenture limits ill
a medicatioo reftiaerator rUb allerina mcdic:atioo ~ and
may resu1c in UIIIoward effects on patilllltll. FailuR to deslpate
i
i
I
'I
i
I
aad w:ritY lUsh aacllow temperature IimitI ~ laboratory
.
tefiipaIora rilb altcriq specimen pmpertieI aDd may teIU1t JD
inaccurate laboratory multi.
I
11-
H'-.7 ·
0 1) a
() I .. cf...
0-/(
I
t
t· .
2 Baled on III inapediau attlM Wah care uait md • review at
Co ec on: A Medication/Supply Expiration Check Sheet will
poUcies and ~ on lQ.126/98, the 1idlity ~ to ea$.Jl'e I be developed by the nursing supervisor. It will identify the
that pollcies aad ~ Wenl developed and implemeatecl . medications by name, the date they expire, and ti'}e signature of
Cot talOViDa outdated suppUcs &om health canJ ue&L
I the nurse conducting the review, There will be a program and
procedure developed explaining how the process is to occur,
P1IIdJoat:
!
Monitoring: The nurse supervisor will develop a·monitoring
Tben was GO poliq, lUld proc:edunl that ideoti6ecl & system mr
system and incorporate monitoring into next year's Continuous
periodic audit ud·removal of outdated medicIl supplies !tom
I Quality Improvement Plan.
padenl care uea. ~ items were rouad ~ the
t
illSp"Crinn ot'the examination rooms md mar1Q\tiOll room on
Responsible Person: Patricia'Wiggins, RN3
10/26198:
I Completion: January 1, 1999
i
I
I,
I
i
e. !ramiNtion rooma:
1) ,. ~ofBetadisHlsarabsdcb-Sixwith aphadoo
date 9i97; ODe with cxpirUiOil date of 1219S.
Surwyor'slnitials
_
DOH $so.oo$omv. wm
Ia~·. JDiIiaJs_OY'-.:..:~ECE'VEL
DEC.l 7 1998
t"c:U';IUlIC:~ ....... """ ...eaVlv_ ..
Ucensing
_
. 12/87/1998
12:38
286-7£15-6654
DEPARTMENT CF
~TH
PAGE
84
STATENI!NT OF DIPlCIENCIES
.
•
AND
PLAN or CORIU!CTION (eca',,'Idoa)
b. LaborMory:
1) 12· Anaerobic blood cukure coDeetIotl boctJeIccpirIdoD elm 9m.
2) 17. Yellow-top (Am) blood umple C()Uection tubeI-
/"
j
,/'/ "'J-,0/
expiration date 3/91.
/ / /
c. S10np Ita:
1) 12 pacbts betadlno rwabtUcb - apintiOIi date 9191.
----~
1('I t S ~
f) (0: /
\_tJ· ---J~
'
./",/
l
'
.
.3. Baed on a reviaw oldie unit', poSey lad procedure maaual 'I
olll0r'26l98 _ tadity 6iJed to esuurethat tba unit's policicl
ADd ~ were revfewecl by 1bI health IUIbority, mc:dicaJ I
directot or 0Iher phyticia1l, aM superiDtendaIl not leu than
every two yean.
.
3. Correction: A system for reviewing standing orders will be
developed. The system should include a policy and procedural
system. It will denote specific time frames, actions to take when
not in compliance. and processes for review and rewrite.
FmdiDp:
Monitoring: The system will be monitored sixty. days from .
implementation. The medical staff will be responsible for ongoing
monitoring and reporting.
.
.. SeYeo orsixly-filw' tWMtioa arden. plU1OC61a, IUd
procedutel rme-ecIln the unit'. 9mDdiDs ~ursins
PtotoCOllllllDUll had beea rcvicwecl OWl'two yean 880. Two
ofmty-rour ItInctiDs ordcrJ, proIOCOIs. and procedures bad no
~ ot.Jl9IOVIl or dates ofte'iJew.
=~~pons.ible Persons:
U•• MD and Patricia Wiggins,
Completion: January 1,1999
b. All ofthe anisa care Jlfocedura ill the unit', Hcdh CIte
MamW wat= daIed April, 1993. A memo lIS tho fi'oDl ortbis
IIWJUI1 Uted tbIt the pr1X1edura it COI'l.ined should be
"nMcwed by 'IIUtIims ItIfI'quutcdy. Tbo-bahh HrW:a UIit
eumotly employs 14 RN's end 3 LPN'1. A liguture sheet in
tbe IDIIIJI1lW!l1lnr.d dcvm lIipatutet dIIed 1993. Six of1hc
eJevm uunaliatcd no toqerWtMk at WCCW.
"
.
Not reviewUIa aad appnMas pol1cia lid ~ can ruuJt
1ft impIcmeDIltioD ofialccurUo lJJIJIor: otlterMse uaacccptabIo
procedures ad improper practice.
SUrveyor's IJIitiaII
DOH S»«I'OtEV. 09·-'R1),......-----
~ECEIVEl.
.
.
DEC 1 7 1993
.-ciCllIl,Cl) ~i, ... ~e, v.v-~
Licensing
12/07/1998
DEPARTMENT CF I-EALTH
206-705-6654
12:30
DivWclIl
AND
.PI»f OFCOIR!CTJON (COlli'" "Ciao)
POBoK4nn
0I)mpI, w ~ ~78S1
. I
85
STATEMDIT <WDEflCIBNCIBS
DEPAllTMENT OFHEALTIi
FIOiIhy LioIuiaa 1Ild~
PAGE
.. StatcmeI1t ofDefldeaciti wbh Re&rence CiWion N~~sIIJceasee'S Plan ofComed011
4. Based OIl a review oCtwo medical tealC'c1s 01\ 10J'26I98;iIic
fiu:Ility &iIed Oft two occaaiOllS to toUow WCCW
0 ' 'l-"
IIIsuucdoD 420.250 eadded "Use or
•
0\
TbeSeld~OIlSllta,""
o,D.. 5.: "ADiamate
kIpt III proloDpst ratrIinc will bo~ obten'ed by a
uairarmtd ....mesnb«. A heahb en ltatfmembet will check
tile restraiPt vthcn blitiaUy apptied on the inmIte ad thea. wiD
make boudy d=ks thaed\er. The _k lIDt1 fiDdinp will be
tossed in tIte imDato Ia1th reconL..(c) o-Iimb 1DIIIt be
reIeuecl for tal (10) mimttes every two (2) houts 011 & rotatins
buis."
~ Tho medicIl~ent with
#1. S2 ; . •
bordcrfiDe
pcnonaJily,
lIIdicales sba \VAl p1ececl in lestIamts OD 101.5198 at 1505.
DocumeawiOD by alJW'liJls staff member 1ncUeates thai the
pllieatts riabt ann was removed &om restraints at J800 and 1haI
she was aboweced at ber ~ n is DOt evident fi'om the
wid. l11DO Table]
• Correction: Nurses will be documenting on the Progress Notes
In the TEC chart. The hourly checks and the release will be
documented.
I
Monitoring: TEe and nursing will be monitorir]g the process with
TSC being the responsible party. The monitoring tools .have
already been deployed and compliance will be reported through
the CQI committee.
Responsible Person:
Wiggins. ~N3
._.Iss,
."1'.'
.
CMHPM and Patricia
.
Completion: November 1, 1998
III'
&
p1accmeut
I
i
I
i
doomzntetiou ifrab'liDt
IDlI cirQJ)adOD WU eheckcd
hourly bdweal1505 aDd 1800 IDd wbcD abe was rdeucd tom "
her nlIUBlms.
b. The medical nlCOftl ofpadent 1 2 . . . - a
JDljor
cpRIIIVC
. cr.
.
i·
I
with a~penona!ity,
t
slOIlp apnea, aud an atrial
I .
!
biaeminY arrhythmia. indicates she was placed in resttainta on
I
10123191. It it unclear when tbe wu placed in resttai.als.
Doc:umentation iDdk:ateI that a IIUf'Iio8 !taftmember checked
I
her~ It 0030. 010~. and 0215, and that me was rcleped
"I'hen: is no ~ ovident that ODO limb WU
released tor teo miDutea every two hours on a rotatbt8 basis.
I
IIS-DOC 015 PERSONNEL
I
at OlIO.
.
(3) ...... c&nI.ldperfo~iDafWlctiou. tub or dlltia
wtIJda ftltl1Ih'e state 1iaMaJ't, ~ 01' nafIb'adoa ill
tile COIlUllUDltJlIaaD COll1p1)' wItb Ita&e Jaw. .
(I) VeriIIcldocl Gf eurrut atdeDdaJIlbaII be oa melD
I
!
I
I
the penoaDII reeord at eHh IDdMcluai perlanala, fllDdio••
.....ml·.1ice1llCl, certiIIcatioa or ........do&.
I
(b) WItIaI. tile racukJ penoalld otrJCe, tIlI~ ,lid be.
.,.."" wltll.ppro~,~..... tor
wriftcado~
or,uce 1IeeIIIun. ~tIo .. rePtndoa.
0'
Correction: Administrative staff has returned to full capacity,
Documentation of a current license for professional employees is
maintained in the Health Care Manager's Offic~.
f
.IUI'"
Surveyor"s JDiti8Js
DOH5.5Q.OOS(lUiV, 09H1)=----~-
Monitoring: ·A sixty day review will be conducted and reported in
the follow up report to the Department of Health. The Office
Administrative Senior responsible for maintenance of the system
will conduct monthly audits and submit reminders to employees.
The system will be referred to the Continuous Quality Improvement
Committee to determine if ongoing monitoring Is ne·cessary.
Responsible Person:. j
SiiSt., Secretary Supervisor
Completion: Decem_b_e_r_1,_1_9_99_)t"yL,.
'RepresciJtatlve's tnbIals
u..:......-
P-ae" of9 Pqes
~ECE'VEC' .
DEC.1 7 199a
,·i:l.CUlUl:r::.~i
.... ,,)t:;IVI... _~
Licensing
.:' " . ; ,
5 hi t
...Q.M,Q.o.d.(midM. ..
,(:::;;::n
@iJI~: .. :
......:. ow:;::
i i
Wi
( .; .
.. ..
.. ..
. b!"«!WmX:;hq<:M.
12/B7/1998
12:30
2B6-705-6654
DEPAImtENT CF t£ALTH
. PAGE
86
STATEMENT OF D£FJCIBNCIES
AND
PLAN OF COUECDON (Cl..tfauM~
• D with Time Table
Baaed on • review ot21 pcnocDd RCOnts. the racmty ailed to
writY c:um::m Iicamure or ccdlcadou ID 8 ot21 records.
1. 30t131lN2~
2. 1 of2 CNA certitIcItes
3. 1 of2 PI)'CbIatrio Social Worbr-31lce.ascs
ot 1 Me:alal HeII1b JN2liceme
S. 2 of3 comnct pllysidaD
4. t
"ceases
Failure to _
did IwIJtb care Itdfmaintain CUI1'8Dt 1iceIIsure
&DdIor cc::ni&ati0ll riJb dcIivay ofheaJth can by'UDquaJUiecl
stafFJDCIDben.
Correction: The infection control nurse will insure procedures and
policies are available for all staff. Additionally, monitoring systems
will be developed to insure Infection Control Inspections are
conducted and on-going. The possibility of an Infection Control
Committee being established will be considered by the CQI
committee.
Monitoring: The infection control nurse will develop a monitoring
system and incorporate monitoring into next year's Continuous
Quality Improvement Plan.
Baaed OD an interview willi an RN3 JUU'SIas superviJor. the
&dJity &iJed to CDII.n thai poUdes ad procedures wurc
estIbiJbcd ad imp1clmantad tIwt rcOac:tccl curraIt in&c:tion
Responsible Person: SlEd I Jllib.CRN3
c:omrolltlDdards.
Comp- ~1.1999
dr.
The IIIJrIins IUpelVillOt ItaIcd that. aldlougb
wen in
props&. tbII mUt bid DO i:daction contml poI1cMa and
.
procedura mplace that IftCC OSHA ItaDdIrds fbr' bcIIth care
wwten, 8UCh U isoIIdOIl pRCIIIIloIlJ (I.e. IWIdard. drop~
I&bome, aDd camact~). wound care. ~
proceduIa. abeqls diJpoaJ. ad waite management.
Ahsence ol8UCb policies ~ procedute:t places ~dl care ILIfr
• riIk fi)f f:Iq)OlUte to comndcable diseaIes.
S~.Inidals
......"..
_
H~?·D?U
•
I
IRepreseawive's Imti.aIs ~(j)_l,.,
DOBS~.09m)
~ECE'VEL"
DEC 1 7 199a
-aCllllle::. ""i,.. "'tll"h.~-
•
licensing
_
.
-
12/B7/1998
12:3B
PAGE
DEPARTMENT I:F .-EALTH
2B6-7B5-6654
87
STA'1ntENT OF DEPICIENClES
AND
PLAN OF CORRSC'nON (emtfnnatiaa)
This finding was verbally reported out as a concern based on a
-gut level- feeling.. The surveyor stated she would conduct a
check. in six months. Her comments in the report reflect mostly
subjective comments made by the nursing·supervisor.
MedicationS and staffing are very critical issues and the previous
Health Cafe Manager felt the comments of the nursing supervisor
did not adequately portray the situation. If there is data available to
6upport Ms. Wiggin's comments,the surveyor should have
gathered m.ore objective data to substantiate the findings. .
Correction: This response will address findings 1 thorough 4.
1.
.. On 10127198. the ~ rII8ted that. due to the
iacttuecl numbeR of COIlttOIled otedi~Ofl' beiJla prescribed,
tho awnbet otbwata required to take A1ediQCions umler direct
supel'VitiOft of aursirlB sta8'hu isroucd tom a daily averaae.of
142.7 (ftom 1/98.5198) to 163 (5198 to preaeat). Tbose
uumbers 'do DOt IDdude medieeMft deIivaift to iDmata in tho
~n WIk nor IIImara who panidpa&c in cacdication IiDea
. in the mcma1 health uDit. ODe DUne is aaip:d the tak of
admiDistcriDs these medications CD weekends.
2. On 10121/98. the
~ supervisor ~ that the tJnc
I
II
I
2.
The nursing supervisor referred to "limited staff. The staffing
issue has been addressed above, but the assignment of
staffing and the systems the staff function in will be addressed.
Such tools as daily assignments 'and patient schedUling
alternatives will be examined and implemented. The majority
of the timing issues with medications can be resOlved with
scheduling the units appropriately. This will be a piece of the
overall corrective action. Plans currently exist to take nonnursing tasks away from nurses and appropriately redistribute
the workload. These issues were addressed in April. but due
to administrative staff shortages. implementation was delayed
until November 24, 1998.
3.
Medication errors have been and are currently being tracked
and are to be reported out to the cal committee in December.
The nursing supervisor has not 'lIna1yzed the existing errors.
Following the assessment, a plan will be devised .and
implemented to correct what problems do in fact exist. Control
of the inmates in medication administration lines has been
addressed, thus decreasing the length of time to administer
1DIdieatkm _ take over two boun each to camp". BCC&USe
of limited sta8iDs. the medleatiou JIJlIC must dose the pin line if
• emcrJeIlGY aria tIlat RqUira hiD'her to respood to
lIPII'8endet in other puts oftbe~. When this oc:cun.
COmpletioD of mcctic3Iion edministmioa is daJaycd. 1'he nuniDa I
supeMaor ItIIcd thIt tho
pilIliDe. wbidl begins at 6:4~
AM, hqucatJy is DOt biIbal uatilll:OO AM, partic:ularJy wboa .
nurse is DOt available iI\ the JDe:dtIl beaJth _ "fbe. evaiDa pill
be. wbicb besiIIIlt 6:45 PM occaioaaUy is not tJnisbed umil
11:00 PM.
mo.
I
II
3. 01\10127198. die DUriIq IlJI*Visor swecl that d1ere.baa bCCIll
an iDcreue ill the JIUIDbcr orincideat RJIOrtltbr medie:atiOO
errors over tha pat seve months, fromS in April. 1998. to 36
in oaober. 1998. 1'hc supavilOr stated dud IMD)' of1!lc:se
errors iDYolved iIIccmect IdendflcatlO1l otlDmata ~ were often
rdated 10 Jtltf'1rYiDK to hurry throuP mcdic:aUon adminiatradoD
ill e4brt to complete the ~c&tiOD UIIe in a timely manacr•.
Surveyor'S 1Idda1s.~
_
The inmate population has increased over the past two years.
This will result in an increase in workload. The issue of
staffing is currently under review. One additional temporary
position has been identified. However. other impacting issues
have come to light which need to be addressed. A new
staffing model is being developed by the department. All of
. the variables will be addressed in the new staffing model.
There is one Labor Relations Meeting yet to be held prior to a
new schedule, with relief built in. being implemented. Staffing
will be addressed through a work study analysis .already in
process through cal.
~'IDidaII_~(jI_'-"
DOH 5»aOS(REV. 091'17)
~ECEtV€l.
DEC 1 7 1993
• :tCllllltt~ "';'''''. ..)~, ~.- ..
Licensmg
_
12/67/1998
12:36
2El6-7ElS-6654
PEPARTMENT CF I-EAL.TH
PAGE
88
STATENENT OF r&1C1ENaES·
»II)
~ OFCORREC'I1ON (CClIdbnradoa)
.~
"
"
:~
-1r---:s:-CIlt~~';"w-ltilt-:-ot::DeD:-:::a"":"'aIQ--'-'es-::wi;:;:th:-;aa:-'::i!:e~tiIiCe:::;::C1:itatf::i::on:;NumhtrU::::;:::~-II...-..::App~H=cmt=:.;·IIII:.:_=.lceosce==.:·I:.::P;.:Im=.=of:.;COI:;,:;:.::J1":.:;ec:ti;o;;·;;;;OD..wit;,;,;·..h_n.U.D_e;;.,;'Io..;;;abl=",-e_
... WCCW". fWd iaIizw:tion 610.070 taIil1cd '"McdielUoll
dmini
A
-.r_4". -tdcb the IID'Iias IUpItYiIor stated baa rcccady
beea nviIed IDd &as been IcaC to DOC H..tquar1a" fix
IJIPfDYIJ. ... u'foDowa:
L
~do_"
". b. Oaco rsw:ry 12 hours (BID) - 8 am· 8 pm
c. 'Ibn:c timIlI a day (TID) - 81m - 1 pm - 8 pm
d. At bcd2ime (HS) -8 pm
1._._
e. QD PM - Anytime. but Mt toODet thaat 4 IlUUD
after last dolO. •
£ BIDPIN-8am-8pm
,. TlDPRN-88J11-lpm-lpm
I
I
.
~
1.
Scheduling; The state wide staffing model will be the basis for
monitoring acceptable staffing levels. In the interim. the
nursing supervisor will develop a system of qata collection and
report it through CQI.
-
2.
Systems: The nursing supervisor will work with the nurses to
develop. analyze. and report the impact of new nursing
systems through ~he monthly report to the superintendent and
the CQI process.
I
I
I
I
i
I
h. QID PllN • 8am- 1 pm - 4 pm - 8 pm
The .current-medication policy will be located and revised with
the above plans.
Monitoring:
mtdDfsht -
.
4.
t1adcl'dIe bIlIIdiDs "F'tdd 1mIructioJi'. D. Stgderd T'P'J'
1. The foDowfDs timellI'O to be used tor routiIJe
Idmjnilbadoa ofmdqtlnn;
a. Ouce" day (QD). 0Dal in 24 houri (12:01~~aftI2
ADydmt, but 110 ~ner than 4 IIUUUt er
- -
medication. New IIghtlng.has been installed and new glass is
scheduled to be installed, both improving visibility. Other
objective issues raised by the nursing staff will be reviewed.
I
I
I
b. UDder the budiDs "FJeld IIIIb1JCIion"'. F.
Errpn
1. A medieat10ll «rot can iBcJudo tho WI'ODI pItieI1l,
. 'I
mecboc1 ofadDliJliltJatio medicadoa. dote, time (+I. 30 I
mimJtea). omisaioa, SlId DUUJerOUS other errora:
Responsible Person:
l1li3113_, RN3
liP• •
Completion: January 1, 1999-
I
Co
UDder the beadb1& "'Procedure":
A Opea campus intnatea It the MaIn Iuti1Ution (Ml),
MiDiDm Security CompouJld (MSC). mid Reception
.Ceatcr OtC) will receive preacn"bed medicadoo or
ova--tbiM:ouater maJiattion II the HeIJth Care Unit
~ durinS ICheduled aeaeaJ populadon
.
medk:asiOf,1Iimes. Schtdu1ed medlcadon r:imes IIC:
6:45_-1:151m
MSC
7:30 am ·1:00 am
8:00 am ·9:00 am
TratzncDt uul EVJluadon
MIlD IIIsdtutloD
Cenrcr (l'EC)
I . . Jd.oaday 0fJIy1
AdmiDiJttative SesrePdoll
11:45 1m - 12:IS pm MSC
12:30 pm - 1:00 pm MaiD Wtitution
1:00pm·2:OO~
7:00 pm. B:4S
7:00 pm. - 8:45 pm
Smvcyor·.1DitiaIs~
TECI~
~D
_
.IY~
I
"
Rep~'s IDitiala
(j)'\......
IXlH,~.rtm1)
~ECE'VEJ_
DEC 171993
.·aCIlI1lC:,wi,~.JCIV.",.-
Licensmg
Plp7of9Paps,
12/07/1998
12:30
206-7E15-6654
DEPARTMENT CF i€ALTH
PAGE
89
STATSMENT OIl DEFICIBNCIES
AND .
PLANOP COIW:CI1ON (emrinuetiCll)
.
'f
,
i.
Ii
App1icant'I/l..lc:ecseo'. PIaD ofCorrectioD with Time Table
WCCW is cumatIy out of Whij'...... with their mecfi«doa
ad",i"ilhaDou .... If ~ by tbeir tWd iDltructiOtl. Faiharo
10 esubUsb and mahabl • accurate &lid timely med1aIloIl
Idm1ni8trItian Iyatem is a riak co'Dia!e health and safely.
)
BSoDOC _ -1UALT.8UCORDS SYS1'EM
.(3) TIIU1." 1M .aftIdeat peI'IOII'" CO UllIft prompt
co..,1edoa. tIIIq. ad ntrIeYal of fIaIrb nconII aad I
I
Baed on inIpcctioD orabe bcaJtb QR uoit oa 10126J98, tile
I
Monitoring: An update will be submitted in sixty days.
i
Responsible Person:
.
orrectlon: All filing has been completed by using limited duty
staff authonzed to file confidential information. This will be an
ong~i~g program.. Medical Records staff will develop a plan
providing for ongoing filing by them with support when needed.
Qa. for leatial Jadiridul ..... ncordI ror aD.ffedcIctI I
.. aD tIaI-.
I
!
=.:- __
I
tidIity tailed to ClllW'CtIlIIt IUf&dem pcnoDDCl were provided to
1iIaI JllOIIIPII7.
CompleUon: November 15. 1998
f
LooIe 6Baa in the medical I'CQOf'dI &rei induded cotuWtatiosl
npoIU that ...... ibur weeks old ad Medieedma AdmbiItDdOil
I
I
ra:ords that W«e et.sed April. 1998.
'lihue to me medical teeatdI promptly may rauJt In omissioa of i
aeecled beabh care cfuc 10 unavaiJability ofiDtormatiou. .
I
t
/~.
'1
IIS-DOC J<tO - MAlN'lENANCE, BOUSUlUlNG, AND
PBEVINTlVE MAINTENANCE REL\TED TO HEALTH
CAUSD.V1C1:S
(1) Pnvtativ. ~ lAd eIedriaI ....ety dad
bIdude tk toIniq:
.
.
(la) A sebedwled ptCYtlItiYe IIalateuaa proaram IbaIl be
..1__
..
...............
_......o..-LU-.._ ....
_ _ aneq....-t.
Hi ART.
17
I~')' !'fD'
I
f
i
orrectlon: A regularly scheduled maintenance program will be
II developed.
All new equipment purchased should come with a
maintenance warranty.
I
.
I
Buecl em iDsp«otioD oltho healdu:..sUIIit IDd m DtteMcw with Monitoring:: Update will be provided with sixty day review.
lUl RN3 nurslnS superWct lonl5l98, the faciJiI:y failed to ensure I
. Acting HCM._
1Iw... _ . _............. _ _ ror
;osponslble.Po",on: d
. the wUi"s medical equip1Dlllll.
•
Busmess Manager
I
P"UIdIJIas:
Surveyor's lDitiaIs
DCR!~.otm)=------
! Completion: January 1,1999
I
Refi..ssentadve"1 InJdals
6)v
~ECEIVE(
DEC 1 7 1993
,·aCIlIllI:l::. ...;,... ..>el ~''''_.
Licensing
.,..
..
12187/.1998 12: 38
DEPARTTENT CF I£ALTH
286-785-6654
ST411!N1!NT OJ DEPIClENCIES
AMD
PLAN OF COUECnON (oaa+n....)
:,.
....,DIIII
10127198
t;iIy.
Oiau.bor. WA
I'
-stilt
!MIt olDe8dtDcies with Refaeuce CItIItion Number
I
inc:Jt.... .II
App1Jcam'IIlJceasee·. PIaD.ofCorreedOll with rime Table
Tbe ........ UllkCl""'Jlrwl .............
~ . . . . . two pulteoximetea, III iacaIdve
.aplrometcr. two IlIoad ,.",... tDdllll1lCOCfaft. TIle
IIUIIiDs -parviIor
dMnwaJID IIIJPIfIrIY ~
~
proarIIIlJbrdlll equfpmestt. .
Ahaeace allUdl pnwoadwo meWcalD dIb ntilia1ion tit
iDI6cd..,. or ~medb1cquipmrm tbr patieat eare.
'.
r...:
---./
~•• IDItia1a _ _~t)\
~e:CElvE."
.
'
...
DEC 1 7 1998
_
I.
-.
i.I.· ~
..-,
~
DEPARTMENT OF HEALTH
Facilities and Services Ucmsing
P 0 8oJI471S2
Olympia. WashingtOn 91S04-71S2
eIlII!l~
''1"
1.,'
's..
STATEMENT OF DEFICIENCIES
AND
PLAN OF CORREcnON
SurwyDlles
11116199
Namo'olFacility
U - NIIIIIbcr
WASHINGTON CORRECTION CEN.TER FOR WOMEN
AddraI
C"ll)'
Zip Code
POBOX 17
GigH¢or
98335
AtfIlliIlislnIc
UcaIIiIIa or CcnilialilID RequiIaneaIa Used
WAC 246-215 Food Service, Multi-Slate Stds. and HS-DOC
This document contains a listing of the deficiencies cited as requiring corrections. The Statement of Deficiencies is
based on the Surveyor's professional knowledge and interpretation ofrequirements for &ciJity licensure or certification.
In the column Applieation'slLicensee's Plan ofCorrec:tion, the statements should reflect the &CiJily's plan for corrective
action and antici sted time of correction.
Statement of Deficiencies with Reference Citation Number
Applicant'slLicensee's Plan of Correction with Time Table
The following environmental cOJ1cems were noted during this
survey::
GENERAL CONCERiVS:
I.
The ceiling vents were heavily soiled in many areas
,
1. Work Order su1::mitted for cleaning of ceiling
including: clinic # 4 ~:<am room. PI toilet rooms. 3 of 4
vents by 2/11/00.
toilet rooms in main visiting area. clinic closet B-129.
chap~1 inmate toilet room, H-# 320, U- #- 519 &. 520.
warehouse toilet room and mail area of mail room, 0-639,
J-B &. C bathrooms. K·B bathroom and custodial closet, LA bathroom.
2.
There were unlabeled spray bonles of assorted cleaning
2. Spray bottle throughout the institution
solutions in several areas including: infirmary laundry. MSC
were checked and labeled by Janitorial Supern
kitchen. C building custodial closet.
CORRECI'ED 11/17/99
~.
CLlN/CI/NFfR.\,IARY:
3.
The large oxygen tank in :; ~ ~:<am room and the small
portabl~ tank in :;. 1 exam room were not stored in :1 secure
manner to prevent accidental tipping.
3. '11le large oxygen tanks have been removed from t
institution. The attachment chain for the smal
oxygen tank has been re-bolted to the wall stuc
by maintenance so it now secure. A memo was sen
out to all staff regarding the securing of the
oxygen tanks. Nurses have been assigned to
specific rooms to ensure compliance for this an
other compliance issues.
I understand the delicien~:y(s) listed and agree to correct them as outlined
above by the dates indicated. I agree to send written notification to
Facilities & • ices Licensing. DOH.
by
declaring the extent to which this
plan OrC!!
The plan or correction must be returned to Department
wccwc99.11oc
of Health within 10 (ten) days of rA&GiEelc:W·E t"
.
FEB 092000
FaC1l1tI8::i am, ,,1:1' VI ... ~
Page I of ~ Pages
..
, DEPARTMENT OF HEALTH
STATEMENT OF DEFICIENCIES
Facilicy Licalsing and Cenific:alion Division
po Box 47852
Olympia. Washington 98504-7852
AND
PLAN OF CORRECflON (continuation)
SwwyDara
N-. otFlCilily
11/16199
WASHfNGTON CORRECTION CENTER FOR WOMEN
CIq
QigHarbor
Applicant'sIlicensee's Plan ofCorrection with Time Table
Statement of Oeficiencies with Reference Citaiion Nwnber
.
4.
Paper cups for drinking and medication as well as cans of
Ensure supplement were inappropriately stored on the 'floor
by the exit door near the medication room for both days of
this survey.
S.
The infirmary laundry was inappropriately stored on the
floor in the infirmary laundry room. Also, re-usable plates
and cups were found in this room in a single compartment
sink next to laundry items. .
6. The shower curtain in the infirmary bathroom was soiled.
4.
Starting inunedicately J the nurses will be
required to put away all supplies by the
end of the shift in which the supplies were
delivered. Margo Johnson has sent out a memo
to nursing staff.
5. "A'memo was sent out to all Health Services staf
including the Close Obersvation Area (COA)
. officers to ensure laundry or cleaning cloths/
mop heads are not left on the floor in the
(COA) laundry area.
6.
The shower curtain in the infirmary bathroom
was discarded.
MAIN CAMPUS:
7.
There were damaged/chipped wall surfaces around the toilet
and sink in the chapel inmate toilet room.
7. Work Order subnitted for repair by 2/11/00.
8.
Ice scoops were inappropriately stored in bins/coolers in
CCU and G-l.
8. GUS Isham and Sgt. Coberly have sent memo's
regarding the ice scoops in G-l to their
staff to ensure proper storage.
9.
The wooden seats in the shower stalls in CCU had
chipped/worn surfaces that were no longer cleanable.
'.
Also. there was a hose attachment in on CCU shower that
had a large build-up of soap scum and mold.
10. There was a significant amount oflint accumulation behind
the dryers in Receiving.
II. There were chipped. cracked and/or damaged wall surfaces
in several areas including: building S-E-9 wall. C-custodial
closet. 256-B pod both custodial closets and A-pod ceiling
inX-111.
Surveyor's Initials ~
DOH 5S0~OS(REV, 09f97 .
9. Work Order sul::mitted for repair and/or
replacement by 3/3/00.
Work
order submitted for repair and/or
replacement by 3/3/00.
10. :Instructed eus to have unit janitor to
clean behind dryers on regular basis-CQRRECIED 2/03/00.
11. Work· . Order sul::mitted for repair by 2/18/00.
"1IfI'-.----
R.p.....,"'tiv.·s Initit".
Page 2 of oJ Pages
.'.
.,
.
STATEMENT OF DEFICIENCIES
.
AND
PLAN OF CORRECTION (continuation)
DEPARTMENT OF HEALTIl
facility Liccnsinglllld Certification Division
PO Box 478S2
Olympia. Washington 98S04-7852
s.-yDara
11/16/99
tor.. ofF8Ciliry
.
,
WASHINGTON CORRECTION CENTER FOR WOMEN
City
Gig Harbor
Sratement of Deficiencies with Reference Citation Number
Applic:ant'slLicensee's Plan ofCorrection with Time Table
12. ~e ,,:,et mops in the ?-l north ~Ustodial clo~et were
12 .
13. One ortwo sinks in the Beauty Shop did not have an
approved air gap/vacuum breaker at the hose attachment.
13. ,.:WOl:.'k,Order subni tted for repair/replacement
. by 2/18/00.
dripp~ng on the floor Instead of Into a mop SInk or app~ove~
contamer.
14. There were damaged ceiling riles in the main kitchen.
.
.
eus
Isham and Sgt Coberly have issued
mODS are stored over
1D9P-...siJJks.·
. directiyes to ensure
Work Order subnitted for repair by 2/18/00 .
14.
15. The damaged vent cover adjacent to the # 3 walk-n in the 5 1'.7 k Order"
main kitchen was not cleanable.
1 . w'or
sumbitted for repair by 2/18/00.
16. There was a hole approximately 5-inches by S-inches in the 16 Work Order subnitted for
. b,v 2/18/.00
exterior brick wall at the main kitchen loading d o c k . '
repal.r J
I'
MSC/CA.~fP:
17.
Several large piles ofsoited linens were observed to being
sorted on the floor in the M-Iarge room. These items must
stored in appropriate cleanable containers to limit the pot- 17. Six fables f'"dr folding have been purchased.
Corrected on 12/15/99.
ential contamination of this area.
18.
Two times during this survey kitchen staff were observed
wrapping clean eating utensils with their bare hands. The
eating surfaces were then subject to contamination.
19.
There was a section of damaged/missing floor surface at
the junction becween the living and dining rooms in the
visiting frailer.
20.
The small stools in the bathroom of me visiting trailer
were chipped iworn and were no longer cleanable.
Surveyor's
Initial~..
VL
DOH SS~OS(REV. 09/97)
18. Instructed Food Manger to see that inmate
wor~ers used disposable gloves When handling
eat~ng
utensils. CORRECTED 2/03/00
19. Work Order subnitted for repair by 2/28/00.
20.
Work Order su1::mit ted to purchase.: a small
stool for visit trailer by 2/28/00.
Repre..nllltive's
Inilia~
_
Page 3 of4 Page~
.......:... : ;;:
!1:=z:a;;;;;;;;;;:;g:;:;::
$.S,;.
a&
STATEMENT OF DEFICIENCIES
.
AND
PLAN OF CORREcnON (continuation)
DEPARTMENT OF HEALTH
Facility Ucensinllllld Certific:adon Division
PO BoJc 47852
Olympia. Washington 98504-7852
Sarw1Data
....alFaaliIy
WASHINGTON CORRECTION CENTER FOR WOMEN
11/16/99
CiIy
Gig Harbor
Statement of Deficiencies with Reference Citation Number
Applicant'slLicensee's Plan ofCorrecnon with Time Table
21.
This surveyor and staffwere'not'~e to verifY that all
electrical outlets accessible to small children were of ~
approved safety type. Also, posted diaper changing
procedures were not available in the visiting trailer.
22.
This surveyor and staff were not able to veritY that the
accessible nO-volt outlet in lhe library had been discon- 22.
Rected.
21. Wo~k order subnitted for approved safety
outlet covers to be purchased and installed
by 2/11/00
Diaper changing procedures posted on 11/18/99.
23 ~
Electrical to check, if not being used a
Lockout Device will be installed by 2/3/00.
23.
There were moldy shower curtains in l-A, K-D and L-8
clC.
24.
The grout was moldy andlordarnaged at several showers. 24. Work Order subnitted for repair by 2/18/00.
including: 1-8, K-A tub and shower and grout was loose
at the handicapped shower in L-D.
25.
All living units were instructed to change
shower curtains on a regular basisCORRECTED on 2/Q3/00.
There was a damaged wall with an unsealed surface in L- 25. Work Order subni t ted for repair by 2/28/00.
C # 320.
26.
There were severnl chairs in L day room which had tom I 26. Instructed CUS to have torn chairs removed
uitcleanable surfaces.
from united by 2/15/00.
27.
A thermometer was not available in the refrigerator in the 27. Instructed CUS to subnit a ESR to purchase a
living unit kitchen used by moms for babies.
refrigerator thermometer for J uni t Mother/
Baby wing.
Surveyor's Initials
~
~
CORRECTED ON 2/3/00.
Representative's Initials
DOH 5S0-00SCREV. 09197'( •
Page 4 of 4
~ages
STATE OF WASHINGTON
DEPARTMENT OF CORRECTIONS
·'.,
WASHINGTON CORRECTIONS CENTER FOR WOMEN
P.O. BOX 77 MS:WP-04 • 9607 Bujacich Rd. N.W. • Gig Harbor, WA 98335-0077
. Plan of Correction
The following is the Washington Corrections Center for Women's plan of correction for
the Statement of Deficiencies for the survey that occurred on 11/16/99.
U3505:
1, 2, 3 J
, Health Care Manager, will amend the procedure attachment to
Field Instruction WCCW 420.250 uUse of Restraints" to clarify that nursing
documentation regarding initial restraint placement and hourly restraint checks will
. . . will develop this flow sheet. Full
occur on a restraint flow sheet. L
implementation of the revised Field Instruction and flow sheet will occur by March 30,
2000. The flow sheet will be filed in the medical record. Monitoring will occur by
nursing as part of CQI. Reporting will occur twice a year at Health Services CQI
Meeting. The Nursing CQI Plan will be amended by 3/30/00 to reflect this activity.
Tracking tools are currently in place.
Note: The Department of Health Summary Statement regarding U3505 does not cite
the Fl/Policy correctly. The policy states that medical staff/nursing staff .are to
check placement and check restraints every hour while the offender is in
restraints. There is no policy requirement for nurses to document when restraints
are released or when they are rotated for the 10-minute release. These are
custody functions. These activities are recorded on a 591 fOrrtl and in the COA
log.
H C M , , - , , reviewed the charts of all offenders placed in restraints on
the dates identified in the survey. The findings of the DOH Surveyors are not
consistent with the charts.
1. b. Nursing Supervisor,
, provided the DOH Surveyors a draft
procedure titled ulnventory Control and Expiration Date Management". •7• •
~., ! : las rewritten this procedure, including identification of specific HSU
staff responsible for specific activities. Inventory sheets and checklists have
been developed to reflect the activity and it will be done on a monthly basis. All
outdated or compromised packages have been discarded. This procedure and
plan will be fully implemented by February 15, 2000.
1
ft
~.,
,eqcled p~pe,
U3505 continued•••
c. All expired and/or compromised items noted in the Trauma Room, Laboratory,
Infirmary, and Storage Room inspections have b~n discarded per Diane
Winniford, Nursing Supervisor. Refer to item #2b for compliance plan.
2. DOH Surveyors are interpreting Field Instruction WCCW 610.070 "Medication
Administration" to include offenders who do not come to medication line as a refusal.
Attendance or lack of attendance at medication line is not addressed in this Field
Instruction. Medication compliance is addressed through CQI studies as evidenced
by CQI Meeting Minutes, Provider Meeting Minutes, and MUltidisciplinary Team
Meeting Minutes. Medication Nurses review the Medication Administration Records
(MARs) daily and notify providers by note or by copying the MAR. Aggregate data is
collected by one LPN who organizes the compliance data and reports findings to the
cal Team, Medical Director, and the Health Care Manager.
Notice of Field Instruction Revision dated 11/24/98, signed by the Superintendent.
and located in the Field Instruction manual identifies:
C.
Missing Pill Line
1. Following the closure of each pHI line, medication records for inmates
who failed to show for mandatory medication will be reviewed.
(Mandatory medications are those which are to be taken at the
designated time and cannot be missed.)
2. Infractions for missing mandatory medications will be written per
WCCW Field Instruction.
Offenders who require mandatory medications as determined by court order or
MedicallMental health Providers are placed on the medical call-out. Refusal to
comply with mandatory medications constitutes cause for initiation of the Inmate
Refusal Form and an infraction. The Multidisciplinary Team meets and identifies
Nursing Case Managers when indicated by the team to promote medication
compliance.
The Field Instruction WCCW 610.070 "Medication Administration" will be reviewed
by . . . . - . HCM, by March 30, 2000.
Note: In a correctional setting, medication lines do not constitute the inference that
offenders are not capfible of handling their own medications. Rather. medication
lines constitute a security function relative to the correctional setting.
U3527:
015.3.b Standard "Personnel"
b. _
Secretary Supervisor, will develop a tracking system for all Health
Services staff to maintain.a current list of staffs' licenses/certifications/credentials.
This will be implemented by March 30, 2000.
2
U3527 continued •••
Note: While DOH Surv~yors were on site. an Office Assistant Senior (OAS) was
able.to verify through the Department of Licensing via telephone that all Health
Services Staff have current licenses.
U3650
050.1 Standard "Infection Control"
1. a. The Nursing Supervisor provided the DOH Surveyors with a draft copy of
Protocols for Application of the DOC policies regarding WCCW. The following
manuals were on site in the clinic at the time of the DOH audit:
• OSHA Bloodborne Pathogen Manual and compliance kit
• NCClS - Standards for laboratories
• Pierce County Health Department for Communicable Resource Manual
• Guidelines for the Prevention and Treatment of TB by the Washington State
Tuburculosis Program.
The following DOC policies are located in the Policy Binders at the Nurses' Station:
• 670.001 - Prevention and Control of Communicable, Environmental, and
Infectious Diseases
• 670.010- Offender ImmunizationsNaccines
• 660.450 - Infectious Waste Management
• 670.016 - Communicablellnfectious Disease Prevention
• 670.017 - Environmental Infectious Disease
• 670.020 - HIV Infection and Acquired Immunodeficiency Syndrome (AIDS)
• 670.030 - Offender Tuberculosis Program
All of the above policies pertain to the Infection Control Program. Combined with the
other manuals available. the four-hour orientation to all staff titled "Infection Control"
that all new employees must attend and all staff have annual two-hour long inservice training on infection control. This provides an excellent competency-based
program. Offenders coming into the institution are provided instruction regarding
infection control as part of the reception program. In addition. offenders receive
additional counselinglinstruction as their health status and risk factors indicate.
In addition to the DOC Policies that are available, WCCW has the following Field
Instructions that complete a comprehensive Infection Control Program:
• 660.450 -Infectious Waste Management
• 670.001 - Prevention and Control of Communicable, Environmental. and
. Infectious Diseases
• 670.010 -Inmate ImmunizationNaccination
• 670.016 - Communicablellnfectious Disease Prevention
• 670.017 - ,Environmental Infectious Disease
• 670.020 - HIV Infection and Acquired Immunodeficiency Syndrome (AIDS)
• 670.030 - Prevention/Controlrrracking of Tuberculosis
3
U3650 continued•••
Plan: r
"'N3, Infectious Disease Nurse, will complete the draft
Infectious Disease manual that integrates the policies with protocols and makes the
Infection Control Program at WCCW specific to the needs of the female offender
population and also the staff requirements. It will also be current with national
standards for a correctional setting and will provide a basis for a competency-based
program for Health Care providers. Dr. Stephen Tabet, Infectious Disease
Specialist, will review the manual prior to implementation. Field Instructions will be
revised/eliminated as needed to implement the new protocols. DOC Policy is
provided by DOC Headquarters.
s:
Time Frames:
• by 1/30/00.
• Draft Infectious Disease manual was completed b~
• Dr. Stephen Tabet is currently receiving and editing the manual and will be
completed by 2/15/00.
• Implementation date by
or the manual is 3/15/00.
• Competency-based program will be developed throughout the year and
implemented as pieces are developed.
• Current HSU CQI will monitor Infection Control as part of its ongoing monitoring
activities. cal currently monitors this activity. Diane Winniford will report twice a
year to CQI.
• . - . . cal Coordinator, will develop the competency-based program
which will include a training video for staff, a training video for offenders, and a
written pre and post test for staff.
b. (2
eveloped a log to track the weekly flushing of the eyewash
station for five minutes. She has assigned a RN to be responsible for this
activity. Procedures have been written. Completion will occur by 2/15/00.
(3) The travel kit's eyewash has been discarded. The nurse assigned to the
trauma unit will ensure compliance, please refer to U3505 2. b. A checklist has
been developed. Periodic audits by. iii
_.
: ,? S
. . . . . . . . . ., and U
; will monitor compliance.
Monitoring activities will occur not less than twice a year.
c. (1) The Infectious Waste Spill Kit was available in the laboratory cupboard above
the phlebotomy chair. The cupboard is labeled "Spill Kit". The Spill Kit is clearly
visible when the door is opened.
There is no corrective action needed. We will continue to have spill kits located
in the Clinic. Staff assigned to the laboratory in reference to outdated
materialslrestock items will utilize a checklist as part of the plan outlined above.
d. The DOH Surveyors failed to note that it is a freezer in the survey report. The
freezer is for offender use; the key for the freezer is kept by the offenders. Only
those offenders who are participating in the Mother Child Bonding program are
eligible. There is a procedure written for this and it includes a temperature log,
4
U3650 continued•••
which is kept inside the freezer. The offenders log the temperature of the freezer
every day. The HCM has a key and keeps it locked in the Narcotics/Sharps box
in the Nurses Station. Currently there are no offenders utilizing this service. so
the freezer is empty and has been for several months. HSU staff are not
involved in any way regarding the care. storage. or handling of breast milk. A
biohazard label is on the freezer. No corrective action is needed.
e. These guidelines refer to Isolation Precautions in Hospitals. WCCW does not
have a hospital.
(1)
• CQI CoordinatorlNurse Educator. issued a memo to all
nursing staff outlining medication administration technique. Plan: All nursing
sfaff will carry a plastic bag for offenders to use to dispose of medication
cups.
Nurses will not handle medication cups that have been handled by offenders.
This is effective on 2/15/00.
(2) Plan: Nursing Staff will direct offenders to wash their hands prior to handling
their multiple dose vials. A sign is now posted in the Nurses Station for
Offenders/Nursing Staff. ~i11 provide nursing staff with a
directive to ensure compliance with the hand washing practice.
f., g. All outdated or compromised packages have been discarded. Please see the
plan outlined in U3505
- 2. b.
.
h. Diane Winniford will develop written procedure and post it in the laboratory.
Implementation of this will occur by 3/30100. Monitoring will occur by checklist as
part of the previously mentioned plan.
i.
The log was present in a yellow folder next to the refrigerator. The ongoing
m~nitoring of this activtty will occ.~r as assigned as part of the above plan.
j.
Multi-dose ophthalmic solutions are the community standard in outpatient
settings in eye clinics. Licensed nursing staff are professionally responsible and
accountable for utilizing aseptic techniques while administering eye drops.
There is no evidence of noncompliance with acceptable standards of Aseptic
Technique per DOH Audit.
issued a memo to nursing staff
directing compliance with Aseptic techniques.
k.
issued a memo to Medication Nurses directing that the pill cuter
will be wiped off with each use. This memo has been posted in the medication
rooms. The nurses responsible for the checklist for the medication rooms will
monitor compliance.
5
U3790
080.5 Standard "Standing Orders"
1. a. b.
·cal Director
. d; P r e ' "
RN3; and
will develop a patient specific program for
utilization of standing orders that provide evidence of patient/provider relationship.
Implementation is 4/15/00.
n' "
080.5 Standard "Controlled Substance Log"
2. ~reviewed the policy with nurses at the Weekly Team Meeting and
issued a directive to ensure compliance with policy. Medication Nurses will comply
with entering both firstand last name of offenders on the log. This will be audited by
an RN3 not less than four time a year to ensure compliance. Implementation will
.
occur on 1/28/00.
6
DEPARTMENT OF HEALTH
STATEMENT OF DEFICIENCIES
Facilities and Services Ucensing
POBox 47852
Olympia. Washington 98504-7852
PLAN OF CORREC110N
AND
Survey DtIes
4/5/99
Name af FaciUty
UcelIIe NIIIIlbc:r
Washingotn Corrections Center for Women
Facility ##004417
Addras
City
Zip Code
PO Box 17
Gig Harbor
98335
Admiais1ruar
UceasiDg at CcnifiaIioa RequimnenIS Used
....
)1.1",;sRabperintendent
Minimum Standards of Health Services Division for Operation
and Maintenance of Health Services in Correctional Facilities
(HS-DOC) Maior Institutions
N01E: This document contains a listing of the deficiencies cited as requiring corrections. The Statement of Deficiencies is
based on the Surveyor's professional knowledge and interpretation of requirements for facility licensure or certification.
In the column Application's/Licensee's Plan of Correction, the statements should reflect the facility's plan for corrective
action and anticipated time of correction.
Statement of Deficiencies with Reference Citation Number
Applicant'slLicensee's Plan of Correction with Time Table
As a result of the complaint investigation, no defiiencies were
found under Health Services Standards for Correctional
Facilities - Major Institutions. relating to the allegations of this
complaint.
I understand the deficiency(s) listed and agree to correct them as outlined
above by the dates indicated. I agree to send written notification to
Facilities & services Licensing, DOH,
by
declaring the extent to which this
plan of correction was completed.
Facility Representative
Date
The plan or correction must be returned to Department or Health within 10 (ten) days or receipt or deficiencies.
03553swtdoc
Page I of 1 Pages
t
••
:
INVESTIGATION REPORT
003553
Investigation #:
028149
State R & A#:
Medicare R & A:
Investigated by :
Date Report is Written:
Stephanie Todak, ARNP, CS
417/99, 4/26/99
Report Written by:
Date of First Contact:
Stephanie Todak, ARNP, CS
4/5/99
Date(s) of Investigation:
Investigation Method:
4/5/99
On-site
Type of FacilitylName:
Address of Facility:
Department of Corrections
Washington Correction Center for Women
9601 Bujacich
Gig Harbor, WA 98335
Synopsis of Investigation:
1.01 Program Manager of Facilities and Services Licensing (FSL) received notice of death of an
inmate according to the interagency agreement. The email notice was forwarded to the
Investigation Unit the same date,. • • •
1.02 IMI died at approximately 8:36 pm at F2. Tentative cause of death is cardiac arrest. Death
was unexpected, IMl collapsed in front of unit. IMl was resuscitated and transported. 1Ml
arrested two more times at the emergency room (ER). An autopsy was requested. 1M 1 was seen
by physicians for Rheumatoid Arthritis and Hepatitis C. 1M1 had hypertension, asthma, and
and
GERD (gastric-esophageal reflux disease). IMl was last seen by a practitioner on 2
was last seen in clinic
g2
1.03 An article was published in a local paper titled "Inmate at corrections center dies after
cardiac arrest".
1.04 The Investigator arrived at the correction facility at 9:30 am on a sunny 53 degree morning.
The Investigator left at 4:00 pm and returned the next day to continue another investigation. The
Investigator presented to the Correction Officers and then to the Superintendent's office to meet
with S I. Later in the morning, the Investigator toured the clinic and infirmary and reviewed
IMl's clinical record. The evidence does not support the allegation.
Sources of Information:
1MI's clinical record which included report of ER visit at F2 and autopsy report.
WS DOH FSL 03553swt.doc
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.~
Page I of;"
.......... m;:::::;y;:,;:::::r;;;::::::::;;.IX'!'.~.*;:::;:;:;:::r:;::;:¥:;;::;#.::;;!& .'.. .&3 ,.. . Jvv.6 1#131%4&;;;::;,(,·
Allegations:
Allegation: Unexplained death at facility.
Narrative:
2.01 Notice of inmate death was received in FSL on 11/19/98. Death was unexpected. Tentative
cause of death was cardiac arrest. IMI had last seen practitioner on
§i_and was seen in
clinic ~ (Tab ). Newspaper article (Tab) titled .....Inmate at correction center dies after
cardiac arrest".
a
2.02 The note in the clinical record of IM 1 for 11/18/98 states that IM1 was in the dining area
and collapsed after a brief seizure episode. IM 1 was unconscious and hardly breathing. IM 1 had
weak carotid pulse. CPR was initiated and IM 1 was transported to F2. IM was thrashing in the
ambulance during transport, so attendants were unable to obtain blood pressure. In the ER, IM 1
was intubated after IM 1 received versad and succinylcholine. Resuscitation efforts were
continued in the ER for 1 V2 hours without success.
2.03 Urine screen was positive for lidocaine and hydroxyzine and negative for central nervous
system drugs. Drug screen was positive for tricyclic antidepressants, but not in elevated amounts.
Hydroxyzine was prescribed as a adjunct to Methadone and taken on a pm basis and taken X14
doses in November. The last dose was takenl1/9/98. A tricyclic was not present on the
medication administration record (Tab).
2.04 Atopsy documented death sequelae of right sided cardiomyopathy (arrhythmogenic right
ventricular dysplasia). No other findings were pertinent.
Conclusion:
2.06 Death was not expected•• Response to the collapse of the inmate was documented in the
clinical record and emergency measures were initiated. It appears that the emergent
situation was handled appropriately. The evidence does not support the allegation. No
evidence of a violation of Mimumum Standards of Health Services Division was found. No
evidence of a violation of standards of care were found.
Other Findings:
None
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.'
INVESTIGATION REPORT
Investigation #:
StateR & A#:
Medicare R & A:
003599
028148
IPJ IE (C i§ il \W IE 10
APR 261999
FACIUTIt:.~
Investigated by :
Date Report is Written:
Stephanie Todak, ARNP, CS
4nl99
Report Written by:
Date of First Contact:
Stephanie Todak, ARNP, CS
4/5/99
Date(s) of Investigation:
Investigation Method:
4/5/99,4/6/99,4/14/99
On-site
Type of FacilitylName:
Address of Facility:
Department of Corrections
Washington Correction Center for Women
9601 Bujacich
Gig Harbor, WA 98335
0.
\jt:HVICES
UCFNS!N~
Synopsis of Investigation:
1.01 Article in the Seattle PIon 12/8/98 titled "Medical chaos at ... prison alleged to judge". New
charges have surfaced describing continued medical "chaos" at the facility almost four years after
the state settled a class-action lawsuit alleging dangerously poor health care at the facility.
1.02 A discussion between the Program Manager and Intake Nurse concerning the last survey
identified two problems which were addressed during the last survey. These included an
allegation of a shortage of medical supplies and many items in stock are beyond the expiration
date; and inmates must wait in line for medication outdoors, even in inclement weather for up to
90 minutes. These were not addressed during this investigation.
1.03 The Investigator arrived at the correction facility at 9:30 am on a sunny 53 degree morning.
The Investigator presented to the Corrections Officer and then to the Superintendent's office to
meet with S 1. Later in the morning, the Investigator toured the clinic and infirmary, reviewed
inmate clinical records, and interviewed staff. Policies, procedures and protocols and practice
guidelines were reviewed. The Investigator left at 4:00 PM; returned the following day at 9: 10
am to continue the investigation; and left at 4:00 PM. Due to scheduling at the facility, the
investigator returned on 4/14/99 at 9:30 AM on a 50 degree sunny morning to continue this
investigation. The focus of this day was the Mental Health In-patient unit (TEe). The
Investigator left at 3:30 PM. The first and last visits were unannounced. The evidence
doeslnot/partially support the allegation.
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Sources of Information:
Staff interviews, review of clinical records, tour of clinic and inpatient unit, review of pertinent
policies, procedures and protocols, facility practice guidelines, DOC Offender Health Plan, tour
of mental health unit (TEC), and schedule of activities and staffing patterns for mental heath unit
Allegations:
Allegation #1: Orders for medications and follow-up treatment are not routinely
carried out.
Narrative:
2.01 In an interview with 52 and during the tour of the clinic, S2 stated that all orders are written
on the Primary Encounter Report (PER), then are sent to the Pharmacy (usually with the clinical
record). The PER is divided into three equal sections on a horizontal plane. Attached to the back
of the Primary Encounter Report are two NCR colored sheets (pink and yellow). The Pharmacy
removes the yellow slip of all orders (even non-medications) then dispenses the ordered
medication, etc. The PER is then placed in the "nursing rack" (usually in the clinical record too).
An assigned Registered Nurse (RN) then transcribes the order onto the MAR (medication
administration record), treatment record or other appropriate form. The RN then signs and dates
the orders with a red pen. The PER goes to the Ward Clerk for input into the computer for the
appropriate "call-out". This "call-out" is a listing of all inmates who are "called-out" of their
assigned area to another area. The "call-out" lists those inmates scheduled for practitioner
appointments, nurse/clinic appointments as well as dental, optometry, etc. The "call-out" is then
posted in all pertinent areas including the clinic to notify staff and inmates. Orders for those
inmates seen by a mental health practitioner are transcribed using this same system.
2.02 The Investigator chose a two week period from 11/26/98 to 12/9/98 and the last two weeks
(3/22/99 to 4/5/99). The Ward Clerk was requested to pick out two dates from the first set, two
dates from the second set, and then choose two dates in December. 5lhe was requested to pull the
"call-out" and sick call log-in sheets for those dates. The Ward Clerk picked 11/26/98, 11/27/98,
12/3/98, 12/18/98 and 3/31/99. With the need for one more date and an earlier pick being the
Thanksgiving holiday a date in February was requested. The Ward Clerk choose 2/4/99.
2.03 The Investigator reviewed the "call-out" lists and sick call log-in sheets. Inmates were
chosen for relation to the allegations in the intake. For example, inmates scheduled for a visit
related to self-mutilation, pain of specific or general nature, migraine or headache, multiple
problems, annual exam, Pap or Pap results or a visit of an emergent nature were chosen. Twentytwo charts were chosen and requested from medical records. Of these twenty-two charts of
inmates, 4 inmates had left the facility, the name of 1 inmate was unable to be interpreted (IM
number was not present), and 1 name was inadvertently left off the list for medical records.
Sixteen inmate clinical charts were subsequently reviewed. One inmate was in the infirmary.
After this chart was reviewed as an acute record, it was noted that this chart was also included on
the clinic list.
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2.04 All except one Patient Encounter Report was signed and dated by an RN as transcribed. The
orders on that Patient Encounter Report, however, were completed Le. x-ray which was ordered
had documented results of x-ray done that date. As mentioned, all other orders were documented
as transcribed. Spot checks of individual orders for medications, x-rays, consults, etc. were
documented as initiated or completed. Follow up clinic appointments were documented or were
documented as a "no show".
Conclusion:
2.05 The evidence does not support the allegation.
Allegation #2: Routine gynecological care is not provided.
Narrative:
3.0 I The newspaper article does not define "routine gynecological care as required by the 1995
settlement (Tab 1).
3.02 The Washington State Department of Corrections Offender Health Plan gives definitions,
covered services, co-payment program, exclusions, and limitations and a description of the
Utilization Review. Listed in the section of Covered Services I. Preventive Care, 3. Female
offenders may receive a breast and pelvic exam, including PAP smear every 2 (two) years. 4.
Female offenders over 40 years of age may receive mammography every 2 (two) years (Tab 2).
3.03 The clinic is staffed with three ARNPs and one physician Medical Director. The three
ARNPs carry a caseload based upon living units of all of the inmates. The Medical Director
carries a case load based upon acuity. Therefore the ARNP is the primary practitioner for each of
the inmates based upon the living unit. In addition, the facility has contract physicians of
specialists such as OB/GYN, Podiatry, Infectious Diseases, X-ray, Orthopedics, Pain
Management. The facility contracts with a local facility, (A2).
3.04 S3 and the staff have developed many protocols for the nursing staff to approach such
problems such as pain, diabetes mellitus, hypertension, COPD (chronic obstructive pulmonary
disease). In addition, they have developed Practice Guidelines for consistent approaches by the
practitioners. Some examples include Preventive Health Practice, Diabetes, Hypertension,
Asthma. Planned additions include Osteoarthritis and Hepatitis C.
3.05 The facility Preventive Health Practice Guideline includes Cervical Cancer risk factors and
screening recommendations (Tab 3); and Breast Cancer risk factors, and breast self-examination,
breast examination by provider and mammography recommendations (Tab 4). Finally, the
Practice Standards list: a breast exam every 1-2 years; pap smear-three nonnal yearly pap smears,
then every other year in low risk women; and mammography every other year in low risk women
over 40.
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3.06 Current CQI subjects includes preventive care, diabetes, asthma, and kites. The CQI project
for preventive care included Pap Smear and Mammograms. Every twentieth chart from a
10114/98 list of inmates was reviewed by the practitioners. 32/692 medical records were
reviewed for a sample size of 4.6% of the current population. Screening guidelines listed in the
Offender Care Plan were checked on three dates. These included pap smear every two years in
lower risk women; mammograms every two years in women over 40. Conclusion of data
demonstrated that routine screening Pap smears and mammograms are being performed as
indicated, and there has been no significant decrease in compliance compared to the July 1998
review. A peer chart review for compliance with pap smears and mammograms is planned for
twice yearly.
3.07 A review of the sixteen clinical records picked as outlined in paragraphs 2.02 and 2.03
demonstrated that 9/15 inmates had a pap smear within the last calendar year. Of those who did
not have a documented pap smear:
1M3 has documentation of low risk with a plan for a pap smear next year.
IM4 refu.sed the pap smear. Documentation of last pap was 7/97.
IM5 and IM6 had a pap smear 2/98
IM7 had a pap smear 3/98
IM8 had no documentation of a pap smear. However, 1M8 had a ultrasound which
documented that herlhis uterus was removed and no ovaries were found.
All of these dates are within the Offender Health Plan and Preventive Care Practice Standards.
3.08 A review of the sixteen clinical records picked as outlined in paragraphs 2.02 and 2.03
demonstrated that 6/15 inmates had documented mammograms or ultrasound of the breast on the
record. These included IM5, IM7, IM8, 1M10, IMl3; IM1S. Two inmates (lMS and 1M10) had
diagnostic work completed due to the discovery of a breast lump. Two additional inmates (1M 11
and IM12) had intake physicals which included a pelvic, pap smear, STD and breast exam and
three other inmates (1M3, IM4, IM9) had an annual physical exam which included the Preventive
Health Practice Guidelines.
3.09 In an interview S3 indicated that the practitioners are attempting to set up a data base of all
inmates, examinations and testing. However, until the hardware/software is available, the
individual practitioners are setting up a log of their group of inmates. Included is the date of the
inmate's last exam and date the inmate is due for another exam. This should assist in tracking
routine exams and tests.
Conclusion:
3.10 The evidence does not support the allegation.
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Allegation #3: Medical conditions that can cause excruciating pain often go
untreated because treatment is not considered medically necessary.
Narrative:
4.0 I A review of the sixteen clinical records picked as outlined in paragraphs 2.02 and 2.03
demonstrated that practitioners included pain management as part of the prescribed treatment.
Two of the visits on the indicated date (1M3 and 1M IS) were for severe headache/migraine. In
each case medication was ordered for pain. 1M3 was then seen four more times within the
ensuing 8 weeks with pain management changes each visit. Another of the inmates (IMI6) had
an appointment with a pain specialist, S4, for management of on-going migraine/neck pain. In
addition, other Primary Encounter Reports in these records were reviewed for pain management
JI for headache associated with URI (upper respiratory
for various issues. 1M 6 was seen
infection); IM4 was seen for self harm action which required sutures; IM6 was seen 11126/98 for
7 Jith dental pain; IM9 was seen for an ankle injury
a broken tooth; 1M10 was seen j
~; and 1M11 was seen for a left hand injury 2
In each case analgesic related to the
severity or potenti~ of pain was ordered. None of the patient records which were reviewed had a
description of pain which could be attributable to kidney stones or to an unknown origin.
un
4.02 Health Services Unit has a Nursing Protocol for Headache (Tab 4). This protocol includes
subjective observations, objective observations and assessment for nursing assessment and
charting. The plan includes standing orders for headache. These include immediate referral to a
provider with certain conditions, migraine headache similar to previous migraines, sinus
headache and muscle tension or other headaches. In addition, the facility has a Practice Guideline
for Headache for the individual practitioners (Tab 5). These guidelines provide the initial step in
the management of headaches. The headaches are classified according to the International
Headache Society Classification Criteria which is attached to the guideline. The guideline further
outlines specific areas for medical history, examination, assessment and treatment. The review of
clinical records of individuals complaining of headaches seemed to follow these guidelines
without deviation. These guidelines and protocols provide parameters for consistency in the
delivery of the care.
4.03 As part of an on-going assessment of pain and headaches or more specifically the Chronic
Care Prevention Clinic, the facility has contracted with a pain management specialist, S4, from a
local university. This physician will become part of a multi-tiered program/approach to the issue
of pain management. S4 will see individual inmates for assessment and for an on-going
treatment. In addition, slhe will assist to develop a multidisciplinary pain management plan to
assist with approaches to inmates with on-going pain. Part of this plan will include a support
group and include the approach that all pain is not necessarily bad. At this point inmates are not
involved with this multidisciplinary team. However, S3 has introduced information about this
multidisciplinary team to the tier representative meeting comprised of inmates. It is hoped that a
volunteer will be found in this group.
Conclusion:
4.04 The evidence does not support the allegation.
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Allegation #4: The psychiatric unit is grossly understaffed.
Narrative:
5.03 The newspaper article did not define "grossly understaffed" nor did the article identify the
nurse who stated "it's chaos down there". TEC (Treatment and Evaluation Center) as the
psychiatric unit is designated is a 25 bed unit. according to S5. 12 beds are allocated to the
residential side for chronic psychiatric inmates and 10 beds allocated for acute psychiatric
inmates and another area for close observation which includes 1: 1 patient contact or every fifteen
minute observation. Staffing for this area includes:
Night Shift (first shift) - 2 Correctional Officers (CO's)
Day Shift (second shift) - 3 Correctional Officers
1 Sergeant
1 Care Unit Supervisor
1 Registered Nurse
2 Certified Mentar Health Counselor 3's (CMHC3)
Evening Shift (third shift) - 3 Correctional Officers
In addition, a CO is staffed for the COA (Close Observation Area). This area will be
moved shortly to a newly remodeled area in the Infirmary. It will contain 5 areas for observation.
It will be staffed by those CO's and nurses in the Infirmary.
On evenings, weekends and night shift the nurse from the clinic is scheduled to
administer the routine medication. administer any other medications which an inmate may need
for a pm (as needed) basis for both emergent and non-emergent needs, restraint checks, plus any
other emergent or non-emergent assessment or intervention.
The CMHC3's and Care Unit Supervisor and Sergeant have variable hours to increase
coverage on the evening shift. However. the staff which provide the therapeutic activities are
mainly scheduled Monday through Friday during working hours. The three individuals who
provide therapeutic activities are the RN and 2 CMHC3's.
5.04 The daily schedule for TEC (Tab 6) begins at 6:00 AM and ends at 10:00 PM (except Friday
and Saturday the schedule ends at 11 :00 PM). Some of the activities are provided or facilitated
by inmates from other areas and by volunteers. These activities include Reading Program and
Mural Project. The mental health staff facilitate 1-2 groups/day and provide individual therapy. If
the mental health staff provide 2 hours of individual therapy a week to an individual inmate and
the inmate attends every group which is offered (morning meeting included), the inmate will get
13.75 hours of therapeutic activities per week or less than 2 hours of therapeutic activities daily.
The rest of the time is spent with activities of daily living, meals, medications. and leisure
activities.
5.05 According to the facility's Field Instruction 630.510 "Treatment will be provided based
upon a written plan:" (Tab 7A). Treatment Plan Requirements include: "at a minimum" a
treatment plan will be completed within 72 hours of admission, 14 days after admission, 30 days
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~
after admission, 'and every 60 days thereafter (Tab 7B). During an interview with S5, slbe
indicated that TEC utilizes a standard Treatment Plan for those inmates admitted for self hann
ideation and a q 15 minute check (Tab 8) or 1: 1 suicide watch (Tab 9). These standard plans are
then modified to an individual inmate.
5.06 Included within the same Field Instruction is the minimum documentation requirements for
crisis, acute and residential care (Tab 7C). In addition to admission and discharge documentation,
a weekly counseling contact will be documented in SOAP format, the comprehensive team
evaluation will be documented and a discharge summary will be completed.
5.07 IM17 has been in the TEC unit during most ofhislher incarceration in September 1998. Slbe
had two evaluations at other DOC facilities. Recent Treatment Plan Addendum have been
completed 2/1199.2/16/99,3111/99,3116/99,3/24/99 and 3/29/99. Due to behavior which is
described as a "substantial history of conflict with others that put ... self and others at risk of
hann", IM17 is currently housed in the Close Observation Area. Slbe is given a limited time with
other inmates which is based on appropriate behavior and adherence to the Treatment Plan. There
are frequent notes in the Inpatient Progress Record.
5.08 IM4 was admitted to TEe on
The initial Treatment Plan was done according to
policy, the 14 day Treatment Plan was not found in the chart. The next two Treatment Plans were
due 9117/98, but not done until 9/29/98 and due 11/28/98 and not done until 12/20/98. The next
Treatment Plan was done early on 2/1199 instead of 2/19/99 and then continued. The Treatment
Plan was continued on this inmate as well as seen in other records. Treatment Plans which are
continued rather than revised tend to be done for staff convenience in a psychiatric facility.
Patients who are not making a change in behavior precipitating a Treatment Plan revision should
be evaluated for a change in approach (which requires a revision of the Treatment Plan).
5.09 IMI8 was admitted to TEC
i51 and transferred back to reception o~.
Treatment Plan was not found for 72 hours despite 1M 18 being on I: 1 and every 15 minute
checks.
5.10 1M 19 was admitted to TEC
&and returned to the unit tw en; admitted
? ;
admittec(
and dischargecd it It Only one Treatment Plan was found for these admissions
and it was for the 2/1/99 admission. It was initial Treatment Plan mentioned above for self harm.
Another undated plan was found addressing treatment issues such as poor anger management,
lack of employment skills, needs to address abandonment issues and grief and loss. The plan was
not dated.
5.11 IM20 was admitted to TEC 1I i 3b and discharged JII?? me Admission and subsequent
Treatment Plans were not reviewed. In 1999 the Treatment Plan which was due for review
~ was extended until 3113/99. No start date is documented, but the inmate signed 11113/98.
No concurrence by the inmate to the extension is documented. On 3/10/99 a note in the Inpatient
Progress Record indicated that staff met with IM20 to review the new Treatment Plan. The
Treatment Plan was not found in the TEC record. It was finally located in a separate Clinic
Record. It does include a start date of 3/1199 and is signed by the inmate, but not dated as signed.
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5.12 Treatment Team consists of the CMHC3's, RN and CUS who formulate the Treatment
Plans. Most CO's have some mental health background from prior institutional training. The
Treatment and Behavior Management Plans are placed in a notebook for use by the CO's during
hours which are not staffed by the mental health professionals. The CO's in tum give feedback to
the mental health professionals on the behavior and compliance of inmates prior to a treatment
plan and on an on-going basis according to S5.
5.13 The Treatment Team Meeting is held on Tuesday and Thursday. This includes the 2CMHC3's, RN, psychiatrist, out-patient psychologist, director of the clinic, CDS and others as
pertinent (Le. counselor or CUS from the living unit). The log from the meetings was reviewed.
Topics included requests for medication changes from staff or the inmate, transfers in and out of
TEC, continued psychosis, behavior problems. During a review of progress notes, these items
were not noted in the Inpatient Progress Notes.
5.14 There are many immediate plans for changes in TEC according to S7. A second RN for the
unit will be added in the immediate future. A half-time recreational therapist will be added.
Volunteer Services will expand coverage in TEC to include Sunday and evenings. Currently as
noted in the schedule, inmates from the institution assist with a mural painting and reading at
bedtime.
Conclusion:
5.15 It is difficult to state that the evidence supports the allegation. "Grossly understaffed"
is quite a subjective statement. However, it is evident that the staff are not completing
Treatment Plans as required in the Field Instruction. The inmates have limited therapeutic
programming and pertinent information is not charted in the inmate's individual record.
The population of this unit are a very difficult population which require individualized
treatment planning and individualized treatment time. It is evident that additional staff
will assist to meet the policies and procedures of the institution and expand the therapeutic
programming of the unit.
Allegation #5: A mental health counselor had an inmate perform oral sex on multiple
occasions and threaten to kill himlher if the inmate told.
Narrative:
6.01 It is not part of the pervue of this agency to determine the validity or the evidence of this
allegation. S8 was interviewed as to actions taken after the allegation was brought to the attention
of the administration. The staff who was accused of the action of receiving sexual favors from an
inmate, w~ jlaced on home assignment immediately. The administrative staff then began an
investigation. The investigation concluded credibility to the allegations by the inmate. The
employee was terminated. S8 showed the Investigator a redacted termination letter,
WS DOH FSL 003S99swt.doc
Page 8
Of.a
(::onclusion:
6.02 The evidence tends to support the allegation, but the evidence was not assessed by the
Investigator. The facility appears to have acted appropriately.
Other Findings:
None
WS DOH FSL 003S99swl.doc
Page
90rl,
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SUPT
(1
NO.
P. 1
2~584685
~~1lIIIH
JUL06'99
STATEMENT OF DEFICIENCIES
DEPARTMENT OF HEAL1lI
.
FlI:ilitics and SeMces Uceallnl
PO Boz .78!2
Olympia. Washinl1CD 98~ogs:V........,---, ~
AND
PI.AN OF CORRECTION
NuDaolFlciBI)'
Washington Corrections Center for W
Addn:sa
P.O. Box 17
AdII1illl1ln1at
..
j
i Superintendent
NOTE:
Sf3temcnl ot Deficiencies with Refere~ce Cir;lrion Number
I
Applicant'slLicensee's Plan of Correction with Time Table
I
I
lNl1lAL COMMENTS'
r
lnvcsligalion
This lnvcsligation~donc &y Stephanie Todak. ARNP. CS in
re~~~'lc to complaint:' 003599 on 415/99. 4/6199. and 4/14/99.
I
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.
\R&At#: 028148
'1
HS-DOC101 - PLAN OF CORRECTION
(4)(b)
1.
1. Based on review of policies and procedures and clinical
record... nn 41t/4199. the facility tailed (0 follow WCCW Field
Instruction 630.510 Memal Health Servic::cs in four of five
Treatment and Evaluation Center (TEe)
CU~ and CMHP~s have
implemented a tracking system to ensure
compliance with Field Instruction (FI)
630.510 regarding treatment plans. The
TEC RN will audit all charts and
Psychologist 3, ~, will maintain
a schedule of all treatment plans that are
due and report monthly to Dr. Robbins
and the Health Care Manager on
.
compliance. All of the following pfans of
correction have a completion date. of
clinical records.
7/15/99.
;;::";nveSligaliCJn report was reviewed
Manager.
.
L.·~~;-II~'·'"
~~I~ :Y~e7 ~
•;
p
HS-DOCI01 - ADMlNISTRATION OF HF..A:Al::TH:----~-
SERVICES
(4) Policies and procedures shall describe and dellae a
sy~tem within each facility which:
(b) Encouraaes and supports approprialc, 5af&:, and
dmely care by qualified personnel,
.
e
'ENrEilED
s~rveYOrSignah1re(~ 'fv\ O~ Iret~
-'-
~
I understand the dcfic:icney(s) listed and agree to comet them IS outlined
above by the d:uc:s indicated. J agree 10 send written nodfieation to
Facilities &: servicee Ucensinr. DOH.
.
by
declaring Ihe CXlCOllO which this
plan or c:orccctlOA was complcrcd.
'th~ pbon ot correction must be returned
~gt)socswldoc
-
to Department nr Health ,,1th1D 10 (teD) dll1S orreceipt ot ddicicnde:s.
QECEIVED
JUL 211999
Page 1 ot 2 Pogcs
J
--
-~-_.
STATEMENT OF DEFICIENCIES
AND
PLAN OF CORRECTION
DEPARTMENT OF HEALTH
Pl1cilities lUId Services Licensing
PO Box 47852
Olympia, WashiDgtDll 985()4.78S2
Suney DIlI:s
Numofflc:ilily
~
u - NlIIIIIlcr
• ..,.i>k.>. '~.""";-.
washiniotil'CoiTeCrlonS Cenrcr for Women
Facility #1004417
AddraI
City
ZipCodc
POBox 17
Gig Harbor ,
98335
AdmiIIiIlnIllr
LkcaIlaa orCatifialicll ~ Used
. Minimum Standards ofHealth Services Division for Operation
and Maintenance of Health Services in Correctional Facilities
reS-DOC) Maior Instimtions
NOTE: This document contains a listing of the deficiencies cited as requiring corrections. The Statement of Deficiencies is
based on the surVeyOr's professional knowledge and interPretation ofrequirements for facility licensure or cenifieation.
In the column Applieation'slLicensee's Plan of Correction, the statements should reflect the facility's plan for corrective
action and anticipated time of correction.
...--superintendent
Statement ofDeficiencies with Reference Citation Number
Applicant'slLicensee's Plan of Correction with Time Table
I
As a result of the complaint investigation, no defiiencies were
.~
found under Health Services Standards for Correctional
'-j. "
Faciliti~ 'Major Institutions. relating to the alleg~~9.~. q.f this
complaint.
..
I
/.//·~co~J.~
. &
~.
. - ..~
_
.,.
~-
.'
;
I understand the deficiency{s) lisred and agree ro correct rIlem as outlined
above by the dares indicated. I agree to send wriuen notification ro
Facilities & services Licensing, DOH.
by
declaring rile extent ro which this
plan of correction was completed.
Facility Representative
Date
The plan or correction must be returned to Department or Health within 10 (ten) days or receipt of deficiencies.
03553swr.doc
Page 1 of 1 Pages
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,
DEPARTMENT OF HEALTH
.------------------------------------------------------------------------._--------------------------------- .....
(Xl) PROVIDER/SUPPLIER/CLIA
/ OF DEFICIENCIES
.'" OF CORRECTION
I
I
(X2)
I
I
IDENTIFICATION NUMBER:
004417
,~~_.
I (X3)DATE SURYIY
I
COMPLETID
I ~
MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
.~;-~;~-~-~;~;~----Jfri-~-~:-~;;;:-~~:-;;;-~·---------·----------------- ..----------.- .
.IASHtNGToN c:OJumCTIomu. CENTERT"; I 9601 BUJACICH GIG HARBOR !}&33S
_._-------------------------------------------------------------_ -------------------------------------------------(X4) 10
PREFIX
TAG
I
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I
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST' BE PRECEE:DE:D BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
1 ID
I
I, PREFIX I
I TAG I
(EACH CORRECfIVB ACfION SHOULD BB CROSS-
REFERENCED TO
THE
AP
,
TB
.
I
PROVIDER' S PLAN OF CORRECTION
(lUI I
IC0t4"I,~'11
DE~ICIE!!~t-.:"!,I"!1CJ'>"~':~ 1111'1'"
ON
-.... -----------------------.--.-.----------------.-------...--------------------.-.. ---()--~~- -~;...---..----- ----····f··
U 000
I MEMO TAG:
I U 000 I
I~
.;cl-~i.·:"· :.
~
"t'I INITIAL COMMENTS
I
1.0 '.' -.~11.;.(:·· .... - .' ~ /)-.
.,.,,::Y' I
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1,/ fl""?,.:''''
':/
_.~t.J'Y
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SURVEYOR: 23KLL -----------J A full survey of this facility was
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on
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Allegation: Overheating in the
kitchen.
.
.•~
conducted by kathleen Landberg, R. S.
10/27/!}&.
'? 1
.
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#'
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This allegation could not be
Substantiated durtng the survey of the
facility.
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No further action required on
investigation # 00337!}.
------------------------------------_ ... ----------------------- ------------------------------------------------------- . ...... .
LABORATORY DIRECTOR' S OR PROVIDER/SUPPLIER REPRESEm'ATIVB' S SIGNATURE
I(Ut ~.
TITLE
I
.
I
------------------------------------------------------------------------------------------------------------ ----·--·----···.'r'l~
By
signiDg. I UDderstand these findings and agree to correct as noted:
-~---------------------------------------------------------------------------------~---------------------------------
STATE FORM
"".
If continuation sheet P09' 1 "" ;
·~··
.
. ,
If
..
,
-- .-- ~b
..~ ¥
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1\
WASHINGTON STATE DEPARTMENT OF HEALTH
(
------------------------------------------_. __ ._ .. _.. _....
(Xl) PROVIDER/SUPPLIER/CLIA
STATEMENT OF DEFICIENCIES
"0'-1'
IX2) MULTIPLE CONSTRUCTION
A. BUILDING,
_
B. WING,
004417
NAME, .~F, ~ROVI?,EROR
SUPPLI~.h tiJ~~~ET ~DRESS,
WASHINGTON CORRECTIONAL
(X4l 10
PREFIX
TAG
U 000
I
rfijIffER
v"F'9's01 BWACICH
SUMMARY STATEMENT OF DEFICIENCIES
FORM APPROVED
~._~._------_... _----------------_._---------------._--~-----------------
IDENTIFICATION NUMBER:
AND PLAN OF CORRECTION
I
AH
-t:'~~./
_
CITY, STATE, ZIP CODE
GIG HARBOR 98335
10
I
I
PROVIDER'S PLAN OF CORRECTION
(X5)
1 (EACH DEFICIENCY MUST BE PRECEEDED BY FULL 1 PREFIX 1
(EACH CORRECTIVE ACTION SHOULD BE CROSS-
!COMPLETION
I REGULATORY OR LSC IDENTIFYING INFORMATION) I
REFERENCED TO THE APPROPRIATE DEFICIENCY)
I
MEMO TAG:
INITIAL COMMENTS
The facility infection Control nurse
requested an on-site visit to
observe changes made in the infirmary
to house mental health/suicidal
patients.
The area has been divided and the
utility closet for the main infirmary
is housed in the new unit. There were
concerns with transporting infectious
materials through the nurse's station
to reach this sink.
A separate utility closet was found
just outside t~ infirmary and is
actually closeJ than the sink in
question.
There were no significant problems
observed with the layout of the n
unit.
I
TAG
1
DATE
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1
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--I
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AA-relil¥-l*lm:"1'Oia's OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
1 TITLE
IIX6) DATE
.,~~"'-~.-----.-.~~~ -,L-e=-------!.&d:-.3------------------.---!~
signing, I understand these findings and agree
orrect as noted:
--------------------------------------_._------------------------------_._----------------------------------------------_._. __ .
STATE FORM
/
If continuation sheet Page 1
··-·-----------··------~--__.,.
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